Product Donation Request
			Required Fields
	Organization Name:
	Organization Address:
	City:
	State/Province:
	Zip/Postal Code:
	Contact Name:
	Telephone Number:
	Fax Number:
	E-Mail Address:
	Technical Contact Name:
	Telephone Number:
	Fax Number:
	E-Mail Address:
	Please provide answers to the following questions.
	Is your organization an IRS 501 C(3) tax-exempt organization?		Yes No
	Or are you a public or private establishment?		Public Establishment Private Establishment
	What is your organization's primary mission? To provide services to the:		Ill Needy Young People Ages 0-18
	Is the geographic area for this project or your organization within 50 miles of a 3Com facility?		Yes No
	Has a 3Com employee referred this request or been involved with your organization as a contributor, volunteer, or director?		Yes No
	How will the networking products be used?
	What will be accomplished with the donation?
	Is your organization capable of installing and maintaining the network?		Yes No
	Can the requested equipment donation substantially complete your network?		Yes No
	Has your organization received 3Com products in the past?		Yes No
	How were 3Com products used?
			By submitting the above details to 3Com and proceeding with this form you consent to the collection, processing and use of that data in accordance with 3Com's Privacy Statement and Information Options Page available for viewing at http://www.3com.com/corpinfo/en_US/legal/privacy.html. Customers within the European Economic Area (EEA) consent to the transfer of that data outside the EEA for any of the purposes described in 3Com's Privacy Statement and Information Options Page.