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Applications to the Reviving Township Economies
1. Contact Information
1.1. Who is completing the Form?
*
I am a business owner who was affected by the July 2021 looting and am applying for support
I am an agent of a partner organisation to Afrika Tikkun
I am an Afrika Tikkun employee
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?
Afrika Tikkun
Alexbiz
Umthombo
Money 4 Jam
Township Entrepreneurs Alliance
Black Umbrellas
Susan Abro
My Dough
Born to Win
Other
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?
*
City of Ekurhuleni
City of Johannesburg Metropolitan Municipality
City of Tshwane Metropolitan Municipality
Sedibeng District Municipality
West Rand District Municipality
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?
*
City of Ekurhuleni
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?
*
City of Johannesburg Metropolitan Municipality
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?
*
City of Tshwane Metropolitan Municipality
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?
*
Emfuleni Local Municipality
Lesedi Local Municipality
Midvaal Local Municipality
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?
*
Merafong Local Municipality
Mogale City Local Municipality
Rand West City Local Municipality
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?
*
eThekwini Metropolitan Municipality
Amajuba District Municipality
Harry Gwala District Municipality
iLembe District Municipality
King Cetshwayo District Municipality
Ugu District Municipality
uMgungundlovu District Municipality
uMkhanyakude District Municipality
uMzinyathi District Municipality
uThukela District Municipality
Zululand District Municipality
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?
*
eThekwini Metropolitan Municipality
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?
*
Dannhauser Local Municipality
eMadlangeni Local Municipality
Newcastle Local Municipality
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?
*
Dr Nkisazana Dlamini Zuma Local Municipality
Greater Kokstad Local Municipality
Ubuhlebezwe Local Municipality
uMzimkhulu Local Municipality
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?
*
KwaDukuza Local Municipality
Mandeni Local Municipality
Maphumulo Local Municipality
Ndwedwe Local Municipality
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?
*
Ray Nkonyeni Local Municipality
Umdoni Local Municipality
Umuziwabantu Local Municipality
Umzumbe Local Municipality
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?
*
City of uMlathuze Local Municipality
Mthonjaneni Local Municipality
Nkandla Local Municipality
uMfolozi Local Municipality
uMlalazi Local Municipality
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?
*
Impendle Local Municipality
Mkhambathini Local Municipality
Mpofana Local Municipality
Msundizi Local Municipality
Richmond Local Municipality
uMgeni Local Municipality
uMshwathi Local Municipality
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?
*
Big 5 Hlabisa Local Municipality
Jozini Local Municipality
Mtubatuba Local Municipality
uMhlabuyalingana Local Municipality
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?
*
Endumeni Local Municipality
Nquthu Local Municipality
uMsinga Local Municipality
Umvoti Local Municipality
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?
*
AbaQulusi Local Municipality
eDumbe Local Municipality
Nongoma Local Municipality
Ulundi Local Municipality
uPhongolo Local Municipality
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?
*
Alfred Duma Local Municipality
Inkosi Langalibalele Local Municipality
Okhahlamba Local Municipality
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:
*
Sole Proprietor
Close Corporation
(Pty Ltd)
Private Company
Cooperative
Not-for-profit organisation (NGO/ NPO/ NPC/ CBO)
3.8. Are you – the applicant – the sole owner of the business?
*
Yes, I am the sole owner of the business
No, the business has a number of shareholders
3.9. Is the business:
*
Woman owned
Youth owned
Black owned
3.10. Do you have a business account?
*
Yes – with First National Bank
Yes – with another bank
No – I have a different type of banking account for the business
No – I do not have a bank account for the business.
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
*
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