Application Form

(Please print, complete this form and send to the contact address ) .
I hereby declare that I have read and studied the code of discipline for the meditation course and accept the seriousness of the rules and regulations. I wish to join the course starting from: .......................... to ......................... If accepted, I promise faithfully to stay for the complete ten days and abide by all the rules.

Date: _______________________ Signature: _______________________

Male/Female: ______________________________________Age: ______
Full Name:___________________________________________________
Contact Address:______________________________________________
____________________________________________________________
Tel:__________________________ Pincode:_______________________
Education:___________________________________________________
Occupation: Business _______Service ______Student _______
Do you have any physical health problem? _________________________
Have you ever had any mental health problem? ______________________
Are you taking any medication? __________________________________
(If Yes to any of the 3 above, please give full details on separate sheet of paper)
Mother Tongue / Native Language: _______________________________
Are you an old student: Yes____ No____
(An old student is one who has done at least one full ten day course with Goenkaji or with one of his authorised assistants)
If an old student, when was your first course:________________________
Where: _______________________With whom (A.T.):_______________
How many courses have you taken:________________________________
10-day:____________ 20-day:_____________ 30/45-day:_____________
any other:____________________________________________________
When was your last course:______________________________________
Where:______________________With whom (A.T.):_________________
If you are a new student, who introduced you to Vipassana meditation?________________________________________________
(To be completed by an old student who has recommended a new applicant to the course)
Old Student’s Name:____________________________________________________
Address:__________________________________________________
_________________________________________________________
_______________________________________Pin code:__________
I have clearly explained the rules and discipline to the applicant, and have stressed that he/she must stay for the full ten days and that he/she must strictly abide by all rules, regulations, timetable, noble silence etc.
I believe, the applicant has fully grasped the importance of them, before he/she signed the application form.
Kindly confirm his/her admission to the course.
I have attended ____________ No. of courses and the last course was on_________________.
Date:___________________Signature:_______________________