ASCII TEXT APPLICATION FORM FOR VIPASSANA MEDITATION COURSE
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Please Note that you cannot type on this form as it appears in your browser (Netscape or Internet Explorer).
You must first: (1) do a "Save As" and save the file on your computer hard disk as "app.txt"; (2) Start a
text processor application such as Windows Notepad; (3) Open the saved "app.txt" file with Notepad and
type in your answers to the questions; (4) Save the completed form again; and, finally, (5) Email the
completed form to registration@paphulla.dhamma.org

Please answer all questions fully. All information will be kept strictly confidential. If you face any 
difficulty in the above steps, please contact us by email (info@paphulla.dhamma.org) or phone.


NAME OF THE CENTER OR OTHER COURSE LOCATION:__________________________;

COURSE DATES:(from)______________(to)______________;

TYPE OF COURSE (10 DAY, ETC.):___________________;

FIRST NAME:___________________________;

LAST NAME:___________________________________;

ADDRESS (Street/P.O. Box):___________________________;

	(City):_______________________________;

	(State/Prov. & Country):____________________;

	(Zip or Post Code):______________________;

E-MAIL ADDRESS:________________________;

TELEPHONE NUMBERS: (Work) (_____)______________;
		   (Home) (_____)______________;
		   (Cell) _____________________;

AGE: ______;

YEAR OF BIRTH: _______;

MONTH OF BIRTH: ________;

DAY OF BIRTH: ______;

Sex:_______;

OCCUPATION:_________________;


Will a friend or family member be taking this course as well? __________;
If yes, please state Name/Relationship: _________________________________________; 

Can you listen and understand English? __________;
If no, please explain (extent of native language, other languages known):
Native Language: _________________;

Have you previously completed a 10-day course with S.N. Goenka or any of
his authorized assistant teachers?  _________________;


For OLD Students:
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Please give following details:

FIRST COURSE INFORMATION:

DATE:_________________________;

LOCATION:_____________________;

TEACHER(S):___________________;

MOST RECENT COURSE INFORMATION:

DATE:_________________________;

LOCATION:_____________________;

TEACHER(S):___________________;

TOTAL NUMBER OF 10-DAY COURSES:

Sat Full Time: ____;

Served Full Time: ____;

Other courses sat (specify)_______________________;

Other courses served (specify)_____________________;

If you are not attending the entire course, please give your arrival date and hour: __________________;
and departure date and hour:   __________________.	 

NEW AND OLD STUDENTS:
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Do you have any physical health problems, medical conditions or diseases? ________;
If yes, please give details (dates, symptoms, duration, treatment, present condition):



Do you have or have you ever had any mental health problems such as, significant depression or anxiety, 
panic attacks, manic depression, schizophrenia, etc.? ________;
If yes, please give details (dates, symptoms, duration, hospitalization, treatment, present condition):



Are you now taking, or have you taken within the last two years, any prescribed medication? ________;
If yes, please give details (dates, types, dosage, present use):



Are you now taking, or have you taken within the last two years, any alcohol or drugs (such as marijuana, 
amphetamines, barbituates, cocaine, heroin, or other intoxicants)? ________;
If yes, please give details (dates, types, amounts, addictions, treatment, present use):



	By completing the spaces set forth below with my name and the date, I hereby 
acknowledge that I have carefully read and understood the Code of Discipline for the 
Vipassana Meditation course for which I am applying.  I agree to stay on the course
site and to abide by all the rules and regulations for the duration of the course.
I realize that a Vipassana Meditation course is a serious undertaking that will require
my full mental and physical health and I affirm that I am fit to participate in it.  I hereby
certify that the above information is true and correct to the best of my knowledge.

NAME: __________________;

DATE: __________________;