MH12 N95 Request Form for Government operated COVID hospital or a frontline worker associated with the local government

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This form is for making requests for MH12 N95 masks used for fighting COVID-19

Email id *

Date *

YYYY

Number of MH12 N95 masks needed *

Intended user of the MH12 N95 masks ( Organization Name ) Eg: Nurses in Naidu hospital *

Senior contact person name at the User Organization *

Email Address of the contact at the User Organization *

Phone number of the Senior person at User Organization *

If you ( who is filling up this form) is not the senior contact person in the User Organization then add Requester Name *

Requester's email address ( who is filling the form) *

Select Priority Categories *

Medical professionals and health workers

Testing centers

Police

Other:

Type of Users to benefit from this MH12 N95 mask *

Government Employees

Other:

Select Region *

Greater Pune

Place within 200Km

Other:

Will you be able to arrange for a donation to Entrepreneurship Development Center (at Rs 35 per MH12 N95 mask) *

Yes

Donation Options

You can donate

1) Online via Bank Transfer
Company Name: Entrepreneurship Development Center
Bank A/c No. 338010100042936 (Savings Account)
Bank Name: Axis Bank;
Branch Name: Baner, Pune
IFSC Code: UTIB0000338

2) By Cheque-- Cash donations at Venture Center Front Desk

3) Via a CSR funding commitment ; Visit: http://venturecenter.co.in/csr/

Will you be able to arrange pick-up of MH12 N95 masks from NCL Innovation Park, Pashan , Pune? *

Yes

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