The House of Dhamma

Application form

Name and date of retreat or workshop

Mr/Mrs/Miss Name
Surname

Permanent address

tel
email address

Temporary address in Thailand

tel.

Date of birth
nationality

Passport or ID number
Occupation

Name and address of a person to contact in emergency


Have you practised Vipassana meditation before? yes no

How long have you practised?

Have you practised other forms of meditation? yes no

If so please give details

I agree to abide by the rules of the meditation retreat/workshop.

Yes No

Please send e-mail at least 4 days before the first day of the retreat/workshop.