| DETAILS OF ORGANISATION / INSTITUTION |
| This Application Form is NOT meant for the Self-Employed Assistance Scheme or the Government Wage Assistance Scheme |
| Organisation / Institution * |
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Registration Number * |
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| Main business activity |
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| Sector * |
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| Type of activity * |
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| Detail of activity * |
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| Postal Address |
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| Building Number |
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Street * |
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| Locality |
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Mauritius Postal Region * |
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| Village / Town * |
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Postal Code |
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| Country * |
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| Contact Details |
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| Telephone Number * |
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Mobile Number * |
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| Email Address |
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Fax Number |
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| DETAILS OF ORGANISATION / INSTITUTION'S REPRESENTATIVE |
| Name * |
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Designation * |
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| Telephone Number * |
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Mobile Number * |
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| Email Address |
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Fax Number |
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| BANK DETAILS |
| Bank Name * |
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Account Holder Full Name * |
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| Bank Account Number * |
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Branch Name * |
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 Please make sure that the bank account number is correct
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| DETAILS OF BENEFICIARIES |
| Number of Beneficiaries * |
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Type of Beneficiaries * |
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| Please specify Type of Beneficiaries |
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| OTHER DETAILS |
| Please give a brief statement on the activities of the Organisation/Institution * |
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| Please give a brief statement on the programme, project or scheme and its relation to COVID-19 (use annex, if any) * |
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| What are the expected outcomes of the programme, project or scheme, based on the proposed activities/output * |
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| Please confirm that the programme, project or scheme is a non-profit initiative * |
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| What type of assistance, including the financial package, which is expected from the COVID-19 Solidarity Fund * |
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| ATTACHMENT(S) |
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| DECLARATION |
| Declarant Name * |
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Capacity in which acting * |
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| NOTES TO APPLICANT |
| (a) Kindly note that one can apply for the Covid-19 Solidarity Fund ONLY ONCE and cannot do any modification after submission of same. |
| (b) The Fund may request for additional information in relation to the application; and |
| (c) False information / incomplete application form may lead to rejection of the request. |
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