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There are three (3) steps in applying to the Computer Lending Library:

First:  You must complete and submit this membership application to the program.

Second:  You must complete a handrwritten letter of request explaining why you need a computer; deliver or mail it to the Selkrk & District Community Learning Centre. (511 Robinson Ave., Selkirk, MB, R1A 1E5)

Third:  Your application and letter of request will be assessed against the program criteria.

*Before you apply, be sure to read the Loan Agreement and our Lending Policies.  Failure to follow these instructions may result in your application being rejected.  If you have questions regarding the program or the policies, call the Selkirk & District Community Learning Centre (204-482-2111).

*Please remember, receiving a computer through this lending program does not mean you own the computer.  Computers are loaned for a specified period of time and recipients are expected to return the computer and its equipment upon completion of the loan term.




511 Robinson Ave.
Selkirk, Manitoba
R1A 1E5   - map -

(204) 482 - 2111

(204) 785 - 1316



Computer Lending Library Membership Application

The information collected in this application is kept confidential.

1. General Information

Name:    Home Ph:
Cell Ph: Work Ph: E-Mail:
Home Address:
City: Prov: Postal Code:

2. Personal Information/Demographics
[This infomation is voluntary, yet helpful to program delivery]

a) Referred by: (or where you heard about the program)
Lord Selkirk Learning Centre Job Quest - Career Services
Interlake Employment Services Public Library
A.I.M. for Work Selkirk Friendship Centre
Employment Centre Selkirk & District Learning Centre
Employment & Income Agency Other Agency
Friend/Family School
Advertising Employer
b) Gender: Male   Female
c) Marital Status:
  Married   Single (no dependents)
  Divorced   Single Parent
d) Language Spoken: English   French   Other:
e) Number in Household (Including self): Adults: Children:
f) Income Source:
Job Own Business Disabiliy Pension Pension
g) What is your current employment status?:
Employed Full-time Employed Part-time Self-Employed Student
Unemployed Disabled Homemaker Retired
h) Do you have any disabilites requiring specialized computer hardware/software?:
No   Yes (specify)
i) Aboriginal Status (if applicable):
Inuit   Metis   Non-Status
Status - On Reserve   Status - Off Reserve
j) Immigration Status (if applicable):
i. How did you arrive in Canada?
Independant   Conventional refugee
Family class Provincal nominee
ii. Current living status:
Permanent Resident   Canadian citizen   Other
iii. Country of origin: Date of arrival:
iv. Have you been English Benchmark assessed? No Yes
If Yes, what level did you attain for each of the following [Level 1-7]
Listening  Speaking  Reading  Writing
v. Are you presently an ESL student? No Yes
If Yes, where? And for how long?

3. Education & Training

a) Education Information
[Highest level attained OR current level attending]
Grade 5 Grade 6 Grade 7 Grade 8
Grade 9 Grade 10 Grade 11 Grade 12
GED Some College Some University Trade Certificate
College Certificate/ Diploma University Degree
Some Trade Training Other
b) Are you or any members of your household currently enrolled in a learning program of some sort?
[E.g. grade school, middle school, high school, adult upgrading, vocational training, college, university.]

If so, please fill out the chart below for each person that is attending.
Person's Name Name of Program Name of School
Sam Grade 3 Happy Thought School
Mary Adult Grade 12 Lord Selkirk Learning Centre
John Health Care Aide Red River College
Person's Name Name of Program Name of School

4. Computer Experience & Training

a) Who in your household will be the:
i. primary user?
ii. secondary user?
b) From the selection below, choose the 5 main reasons you have for borrowing a computer. Of these 5 choices, rank them from 1 to 5.
(1 is your main reason; 5 is your least reason)
School (K-Grade 12) General family needs
Own business Post secondary studies
Internet access E-Mail
Employment upgrading/Training Games
Job search Online courses/ Distance Education
Computer Awareness Other
c) Have you ever used a computer before? No Yes
If you answered Yes, which computer programs have you used?
[Please include computer games]
Program / Game Name(s)
(e.g. Word, Excel, PowerPoint,
KidPix, Sims)
How well do you know how to use it?
(little bit, good, pretty good, very well)
d) Which computer programs have other members of your household used?
[Please complete this portion of the questionare for each other person who will be using the   borrowed computer. If you need more space, please use the bottom additional notes area.]
i Person's Name
Computer Program / Game Name(s) How well do they know how to use it?
ii Person's Name
Computer Program / Game Name(s) How well do they know how to use it?
e) If you have any additional information or require more room to complete a section, please enter it here.