Laptop Request Form

Welcome to the SEIU Healthcare 1199NW Multi-Employer Training and Education Fund!

This short-term laptop loan is available free of charge, with no fees attached.

The duration of the laptop loan is not intended to exceed 90 days or approved Training Fund program. Extensions may be granted for one term (or 90 days for short-term programs). Training Fund staff will work with you to overcome barriers and create a plan for a permanent solution.

At the conclusion of the program, the laptop will need to be returned to Eduscape.

This is our laptop request form - fill this out to submit your request for a chromebook to help support your academic and job training needs!

These chromebooks are provided by our partner, Eduscape. After submitting this form our staff will review your eligibility, contact you if we questions, and move forward with having our partner, Eduscape, mail you a device.

Orders are processed by our partner every Tuesday and Friday with shipping being roughly 5 business days. We will let you know when we have submitted the order on your behalf and have a tracking number.

Need access to Microsoft Office products like Word or Excel? We have you covered! Each chromebook request will also come with a custom email from our Virtual Healthcare Institute where you can access online versions of the common Microsoft products for schoolwork and emailing. You don't have to use them, or the email address, if you have your own but they will be available.

On the next page you'll give us your contact information, where to send the laptop, and how long you intend to use it. Let's get you started by clicking 'Next Page' below!

NOTE: PER DIEM & CONTRACT EMPLOYEES ARE NOT ELIGIBLE FOR THIS SERVICE

Contact Information

First Name

Middle Initial

Last Name

Your Home Address for Shipping

Address (Including apartment or building number)

City

State

Postal Code

Is your home address OK to ship a laptop to?

YesNo, I'd rather you ship it to a different location

Tell us where you would like it to be ship to (could be a school or work location). Provide the full and complete address.

Any special instructions for delivery?

Preferred Phone Number

Mobile Phone

Home Phone

Work Phone

May we text you? Message and data rates from your carrier would apply.

Preferred Email

Email (Please be sure you DO NOT share this email with another hospital worker such as a family/friend/co-worker/spouse/child - each person needs to have their own email. You can use your work email if you don't have a personal email.)

Eduscape, our partner, would like to be sure they have a personal email on file for you in order to send you instructions and updates on your laptop request. Please give us a personal email as well.

Employer

Department

Job Title

Bargaining Unit

Current FTE (To calculate, divide your hours worked in a week by 40 (32/40 = .8 FTE))

Date of Hire (mm/dd/yyyy format)

NOTE: PER DIEM & CONTRACT EMPLOYEES ARE NOT ELIGIBLE FOR THIS SERVICE

Lead Source

Record Type

Use Information

Start Date of Laptop Use

General End Date of Laptop Use

General Use Purpose

Tell us a little bit about how you intend to use it. If you want to use the Microsoft products like Word and Excel please let us know.

Contact Information