Form 45-L91
First Name
Last Name
Street Address
Delivery address for computer
Address Line 2
City
State
Zip Code
Email Address
Phone Number
Date of Birth
Do you require any accommodations or support (e.g., hearing, speech, or accessibility assistance) for orientation?
If yes, please describe
Requested employment start date
Computer Deposit
By submitting this form, you acknowledge and agree to pay a $140 refundable deposit to receive a laptop computer required for your employment duties, which will be fully refunded after 30 days of employment or upon return of the laptop, whichever occurs first.
