MH12 N95 Request Form for Government operated COVID hospital or a frontline worker associated with the local government
This form is for making requests for MH12 N95 masks used for fighting COVID-19
Sign in to Google to save your progress. Learn more
Email id *
Date *
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 *
Type of Users to benefit from this MH12 N95 mask *
Select Region *
Will you be able to arrange for a donation to Entrepreneurship Development Center (at Rs 35 per MH12 N95 mask) *
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:
Will you be able to arrange pick-up of MH12 N95 masks from NCL Innovation Park, Pashan , Pune? *
Clear form
Never submit passwords through Google Forms.
This form was created inside of Report Abuse