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(Please write clearly and in BLOCK LETTERS)

Name: ____________________________________________________________

Address: __________________________________________________________


Mobile No.: ________________________________________________________

E-mail Address: ____________________________________________________

Completed Part-I course in the Year: ____________________________________

Part-I course teacher: ________________________________________________

Have you done the following courses? If yes please mention the Teacher and year.

Part-II: Teacher _____________________________ Year ___________________

Part-II: Teacher _____________________________ Year___________________

DSN: Teacher ______________________________ Year___________________

Sahaj Samadhi: Teacher______________________ Year___________________

Blessings Course: Teacher ___________________ Year___________________

Would you like to do the above courses in the near future? If so when?

Part-II: ____________________________ DSN: ___________________________

Sahaj Samadhi: ____________________________________________________

Blessings Course (Eligibility 2 part II Courses):____________________________

Would you like to join us in any of the following Seva activities?

( Tick against the appropriate option/s )

o Making Phone calls

o Taking courses in slums/BMC schools
o Assisting Part-I courses
o Organizing courses in slums
o Sponsor for events

Vyakti Vikas Kendra, India, No. 19, 39th A Cross, 11th Main, IV T Block, Jayanagar, Bangalore – 560 041