DESIGN CLINIC REGISTRATION FORM FOR
Design Consultant
APPLICATION FOR DESIGN CLINIC SCHEME FUNDING ASSISTANCE
(To ensure the easy and correct processing of your application, please ensure that the application form is filled up completely and neatly. Where information is not available or applicable, please indicate accordingly. Please enclose all supporting documents as
requested in the form).
1.   GENERAL
a.Name of Design Consultant (please mention initials as Mr.,Ms.,Mrs. etc.)
*
b.Group membership/Associated with
2.CONTACT INFORMATION
Contact Person (please mention initials as Mr.,Ms.,Mrs. etc.)
*
Address
*
District
*
State
*
PIN Code
*
E-Mail
*
Phone No
Mobile
Fax
Website
3.DESIGN EXPERTISE DETAILS
a.Work experience (In Total number of years)
*
b.Functional area of Specialization / Interest
*
 Industrial design
 Branding and Advertising
 Visual Communication
 Textile Design
 Design and systems Thinking ( Product / Process / Business Design )
 Products/service specialization.
 Other (please specify)
c.Preference for Industrial Sector (Textile, Automobile, Pharmaceuticals, etc)
*
d.Consulting and service activities Information and references
i   
ii
iii
iv
4.DESIGN CLINIC INFORMATION
If already registered with MSME Design Clinic or Other such programmes please mention Other MSME projects information*
 Yes
 No
5.Please mention the activities you would be interested to take up for DC
 Design Sensitizing Workshop -
1 Day workshop/seminar
 Need Assessment Survey and Design Clinic -
3-4 Days workshop/seminar
 Design Projects -
Scheduled project
6.Prefered Zone for Design Clinic Projects.
 East Zone
 West Zone
 North Zone
 South Zone
7.Attach a file (e.g. Visiting Card, Portfolio...)
(Maximum size of the zipped folder attachment should mot be larger than 10mb)
 
SUBMIT