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Applications to the Reviving Township Economies

1. Contact Information
1.1. Who is completing the Form?*
If you selected i am a business owner , go to question 1.3
If you selected i am a agent of a partner , go to question 1.2
If you selected i am an Afrika Tikkun employee , go to question 1.2
1.2. Please complete your (agent/employee’s) contact details:
Email Address
Contact Number
Which Partner Organisation do you belong to?
If you selected other. Please type the partner organisation name below
1.3. Complete the contact details of the Applicant so we can get hold of you
1.3.1 Complete the contact details of the Applicant so we can get hold of you*
1.3.2 Complete the contact details of the Applicant so we can get hold of you
1.3.3 Complete the contact details of the Applicant so we can get hold of you
2. Exclusion Criteria
2.1. Is your business located in either KZN or Gauteng?: Yes/ No*
- Yes
- No
2.2. Is your business South African owned?*
- Yes
- No
2.3. Was your business directly affected by the looting and civil unrest that occurred in July 2021?*
- Yes
- No
2.4. Have you received any financial support to assist you to cover the damages of the looting? This is a multiple choice question with one answer.*
- Yes – I received financial support that covered the full cost of the damages.
- Yes – I received financial support which partially covered the cost of the damages
- No
2.4.1 If you received financial support partially please fill in the below organisation’s name and total amount received
Organisation’s name
2.4.2 If you received financial support partially please fill in the below organisation’s name and total amount received
2.5. Do you give consent for Afrika Tikkun to store, process and verify the information provided for the purpose of processing your grant application?*
- Yes
- No
3. Business Information
3.1. Complete the registered and/or trading name of your business
3.2. Complete the business street address
Street Name & No Suburb/ Town Postal Code
3.3. Select the province the business is located in:*
- Gauteng (if selected, proceed to question 3.4)
- KwaZulu Natal (if selected, proceed to question 3.5)
3.4.1 Select the Gauteng District municipality the business is located in?*
This is a drop down menu with one answer per drop down. Thereafter proceed to question 3.6.
3.4.2 Select the Gauteng Local municipality the business is located in?*
This is a drop down menu with one answer per drop down. Thereafter proceed to question 3.6.
3.4.2 Select the Gauteng Local municipality the business is located in?*
This is a drop down menu with one answer per drop down. Thereafter proceed to question 3.6.
3.4.2 Select the Gauteng Local municipality the business is located in?*
This is a drop down menu with one answer per drop down. Thereafter proceed to question 3.6.
3.4.2 Select the Gauteng Local municipality the business is located in?*
This is a drop down menu with one answer per drop down. Thereafter proceed to question 3.6.
3.4.2 Select the Gauteng Local municipality the business is located in?*
This is a drop down menu with one answer per drop down. Thereafter proceed to question 3.6.
3.5.1 Select the KZN District municipality the business is located in?*
This is a drop down menu with one answer per drop down. Thereafter proceed to question 3.6.
3.5.2 Select the KZN Local municipality the business is located in?*
This is a drop down menu with one answer per drop down. Thereafter proceed to question 3.6.
3.5.2 Select the KZN Local municipality the business is located in?*
This is a drop down menu with one answer per drop down. Thereafter proceed to question 3.6.
3.5.2 Select the KZN Local municipality the business is located in?*
This is a drop down menu with one answer per drop down. Thereafter proceed to question 3.6.
3.5.2 Select the KZN Local municipality the business is located in?*
This is a drop down menu with one answer per drop down. Thereafter proceed to question 3.6.
3.5.2 Select the KZN Local municipality the business is located in?*
This is a drop down menu with one answer per drop down. Thereafter proceed to question 3.6.
3.5.2 Select the KZN Local municipality the business is located in?*
This is a drop down menu with one answer per drop down. Thereafter proceed to question 3.6.
3.5.2 Select the KZN Local municipality the business is located in?*
This is a drop down menu with one answer per drop down. Thereafter proceed to question 3.6.
3.5.2 Select the KZN Local municipality the business is located in?*
This is a drop down menu with one answer per drop down. Thereafter proceed to question 3.6.
3.5.2 Select the KZN Local municipality the business is located in?*
This is a drop down menu with one answer per drop down. Thereafter proceed to question 3.6.
3.5.2 Select the KZN Local municipality the business is located in?*
This is a drop down menu with one answer per drop down. Thereafter proceed to question 3.6.
3.5.2 Select the KZN Local municipality the business is located in?*
This is a drop down menu with one answer per drop down. Thereafter proceed to question 3.6.
3.6. What do you sell or what industry are you in?
3.7. Select your business type from the list:*
3.8. Are you – the applicant – the sole owner of the business?*
3.9. Is the business:*
3.10. Do you have a business account?*
3.11. How many employees in the business (including the owner)?
3.11.1. Full time staff number
3.11.2. Casual/ seasonal staff number
3.12. Provide a sense of the profile of your employees (including the owner)?
3.12.1. Women number
3.12.2. Youth number
3.12.3. Persons with disabilities
4. Incident Information
4.1.1. Which of the following describes what happened to your business during the looting?*
- My business was burnt
- My business was broken into and vandalised
- There was structural or infrastructure damage caused to my business eg. Broken windows, doors, gates, plumbing, shelving, ceilings, etc
- My equipment was stolen and/or destroyed
- My stock was stolen and/or destroyed
- Other
4.2. Estimate the total damage or loss incurred by your business as a result of the looting:
All numbers must be written without (R) and with no cents, commas or full stops.
Ts/Cs*
- Agree to the terms and conditions
- Would you like to receive marketing communications from Afrika Tikkun periodically?

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Ground Floor, Eastwood Building
57 6th Road,
Hyde Park South Africa

Tel: +27 11 325 5914
Email: info@afrikatikkun.org

NPO: 021 – 892
PBO: 18/11/13/2470
NPC: 1998/15527/08

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