Application for Disability-Related Computer Pricing

Applicant Demographic Information

Name *

First Last

Address *

Street Address City State Zip Code

County *

Contact Phone *

Email *

Enter Email Confirm Email

Family member with disability in household *

Same as above
Different

Name *

First Last

Disability Category *

Please select at least one (1) disability category

If other, please specify *

State or Federal Assistance Benefits Received *

Please select at least one (1) of the following state or federal assistance benefits that you are currently receiving

AHCCCS/Medicaid
Federal Public Housing Assistance (Section 8)
Low Income Home Energy Assistance Program (LIHAEP)
National School Lunch Program (Free Lunch Program)
Social Security Disability Income (SSDI)
Supplemental Security Income (SSI)
State Children’s Health Insurance Plan (SCHIP) / KidsCare
Supplemental Nutrition Assistance Program (SNAP) Food
Temporary Assistance for Needy Families (TANF)

Verification of State or Federal Assistance Benefits

Please upload, email, fax or mail a copy of the document from the state or federal agency that verifies you are currently receiving the benefit selected. Your application will not be considered complete until the verification document is received.

Max. file size: 256 MB.

If you are unable to upload a file at the time you submit your application, you may send it to us using one of the three methods below:

1) Scan and email to Martha.lewis@nau.edu
2) Fax to 602.728.9535; attention Martha Lewis
3) Mail to: Martha Lewis, AzTAP, 300 W. Clarendon Ave, Suite 475, Phoenix, AZ 85013

After your application has been processed and approved, you will be provided with specific login information that will allow you to purchase the computer directly from the Achieve website at their current discounted prices. Please note that the device you receive will have similar features to the one you ordered, but may not be exactly the same!

If you have questions or need assistance, contact Martha Lewis at Martha.lewis@nau.edu; 602.776.4670, 800.477.9921