DESIGN CLINIC REGISTRATION FORM FOR
MSME Unit
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 MSME Unit
*
b.Registered as (please tick)
*
 Proprietorship
 Partnership
 Private Limited
 Other (please specify)
c.Established since
*
d.Total Number of Member Units
*
 Less Than 50
 50 to 100
 1000 to 500
 500 and more
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.INFORMATION ABOUT THE UNIT
a.Industry Type (Textile, Automobile, Pharmaceuticals, etc)
*
b.Nature of business
*
 Manufacturing
 Processing
 Service
 IT
 Trading
 Craft
 Other (please specify)
c.Total turn over of Unit in last FY
*
d.Tyep of products /Services (Please Mention)
*
e.If member of any Cluster Representation/ Association/ Group
*
f.Sales & Profits
 Sales Turnover & Profit for last 3 years
(Please attach a copy of FinancialStatements)
 Projected Sales & Profit for next 3 years
(excluding current year)
4.DESIGN CLINIC INFORMATION
a.
Has the MSME been granted any financial support from Design Clinic before? If yes, please list all project references and amount of funding involved. Please also list other Design Clinic applications of the MSME pending approval.*
 Yes
 No
b.
Has the Association of MSMEs been granted any financial support from Design Clinic in the name of another MSME? If yes, please list all project references.*
 Yes
 No
c.
Please provide any other supporting information (if any).
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.Attach a file (e.g. Visiting Card, Portfolio...)
(Maximum size of the zipped folder attachment should not be larger than 10mb)
 
SUBMIT