Support Network for Malaysian Women Renunciants (SNFRENMS)

http://snfwrenms.wordpress.com/
Application Form for Residence in Gotami Vihara

Photo

Personal Data
Name/Ordained
Name:
Date of birth:
Address:
Passport/IC No.:
Citizenship:
Email address:
Telephone No.:

Mobile

Home

Period of Stay
Arrival Date:
Departure Date:
Emergency Contact
Names and contact information of next of kin/kalyana mitra
1. Name:
Relationship:
Contact Number:
2. Name:
Relationship:
Contact Number:
Information on Ordination
Type of Ordination:
Year of Ordination:
Name of Teacher(s):
Contact information of Teacher:
Email:
Special Needs*

Tradition:
Place of Ordination:

Telephone No.:

Health Information
Do you have a current or recurring physical or mental health condition
that
may require extra care and attention during your stay?
Yes/No
If yes, please specify:
Physical health
Gotami Vihara: K37-C, Jalan TK 1/11A, Taman Kinrara, 47180 Puchong, Selangor Darul Ehsan, Malaysia
Email address: gotamivihara2013@gmail.com

problem:
Mental health problem:
Are you on medication?
Yes/No
In case of an Emergency, any doctors name and contact number:
Drug Allergies, if any:
Food allergies or restrictions, if any:
*Information requested is meant for your well being and of other
residents. It will be kept in strictest confidence. Withholding of any vital
information on your health may affect your application for future stay in
Gotami Vihara.
Your Profile (Optional Information)*
Qualifications:
Skills/Experience/Strengths:
Any other Information (Please specify)

*It will be very useful if you can furnish us with the above information for
publicity and to facilitate arrangement for talks, sharing and training.
Note: Maximum of 3 months stay. May be extended subject to review.
Name of Applicant

Date

________________________
_____________________
~~~Thank you~~~

Gotami Vihara: K37-C, Jalan TK 1/11A, Taman Kinrara, 47180 Puchong, Selangor Darul Ehsan, Malaysia
Email address: gotamivihara2013@gmail.com