DESIGN CLINIC REGISTRATION FORM FOR
Design Institution
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.Registered name of Institution
*
b.Registered as (please tick)
*
 Trust
 Educational body
 Government institution
 Private Institution
c.Affiliation/Recognition by (If Applicable)
*
Govt. Body
Industry Body
International Group
Institutional Body
d.Established since
*
e.Courses conducted for
*
 UG (Under graduation)
 PG(Post graduation)
 PhD
f.Total Number of Design/Technical Faculty and Staff.
*
 Less Than 10
 10 to 50
 50 to 100
 100 and more
g.Total Number of Students
*
 Less Than 100
 100 to 200
 200 to 500
 500 and more
h.Discipline and courses undertaken as study programme:
*
 Industrial design
 Visual Communication
 Design Management
 Others area (Please Write)
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
Besides education is the Institution Participating in Consulting services and workshops*
 Yes
 No
Institute’s work experience in area of Consultancy (Total number of years)
*
Name the sectors in consulting areas (e.g. Crafts, Industrial processes,
Product innovation, etc)*
i   
ii
iii
4.MSME DESIGN CLINIC DETAILS
Is Institution associated with MSME for other activities*
 Yes
 No
If yes Please mention the programme/scheme*
5.What activities the Institute would be interested to take up for DC
 Design Sensitizing Workshop -
1 Day programme
 Need Assessment Survey and Design Clinic
 Design Projects
6.Attach a file (e.g. Visiting Card, Portfolio...)
(Maximum size of the zipped folder attachment should not be larger than 10mb)
 
SUBMIT