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As taught by S.N. Goenka ✔
in the tradition of Sayagyi U Ba Khin OLD ST DENT NEW ST DENT

COURSE APPLICATION FORM

INCOMPLETE FORMS WILL NOT BE ACCEPTED. PLEASE FILL UP ALL FIELDS.
Course Dates: From 2023-06-21 To 2023-07-02 Center: Dhamma Dhaja

First Name Name Last Name ( rname)

Amritpal Singh Gender:
Male ✔
Address (with ity, ist , o ntry etc ):
148-F SBS NAGAR Female
PAKHOWAL ROAD Date of Birth
Ludhiana, Ludhiana, PB, IN
(dd/mm/yyyy):
Pin code: 141013
03 01 /______
_ _ / ___ 1980
Contact Home: +919464090514 Mobile: 7589169960
Detai s Work: 7009966188 mail: amrit_aaa@yahoo.com Age - 43

1. P Passport adhar ard ✔ P ard National ID 370214628899

(Mention your ID num er a o e)
2. Occu ation: Past Present ✔
octor awyer n ineer I siness / cct t dent efence
o t ( lass- ) o t ( lass- ) eal state ric lt re eacher Politician ther(Please pecify) ✔

Education: M.A.BED education/training

3. Name Of Organization: Govt school Teacher

4. Will a friend or family member be taking this course as well?

If yes, write Name and relationship No ✔ Yes

5. U
GULZAR SINGH (Father ) - +917009966188
6. ow well do yo nderstand the Hindi 1RQH Basic Intermediate ✔ Expert
lan a e(s) in which this co rse will be cond cted English 1RQH Basic Intermediate ✔ Expert
1RQH Basic Intermediate Expert
Preferred language of Instructions/Discourses: Punjabi 1RQH Basic Intermediate Expert ✔

For Old Students Detai s of courses done in t e tradition of Sayagyi a in as taug t y S.N. oen a
1. First Course: Date __________________ Location _____________________ Teacher(s)

2. Most Recent Course (Sat): Date ______________ Location ________________ Teacher(s)

3. Teen -day P pecial o rse -day -day -day -day eacher s self co rse hamma er ice

. Have you maintained your practice of Vipassana meditation since your last course? No Yes
If yes, please give details (how much time daily, etc.).
For All Students (New and old students)
i assana is a non sectarian tec ni ue ic aims for t e tota eradication of menta im urities and t e
resu tant ig est a iness of fu i eration. But in order to
faci itate a smoot transition of your course e re uire t e fo o ing ea t information.
1. Do you have any past/present - physical health conditions (If yes, please i e complete No ✔ Yes
details s ch as medication, dosa e, treatment, hospitali ations etc ):

. o yo ha e any past/present history of psycholo ical treatment (If yes, please No ✔ Yes
i e complete details s ch as medication, dosa e, treatment, hospitali ations
etc ):

3. Are you now taking, or have you taken within the past two years, any prescribed
No ✔ Yes
medication? (If yes, please i e complete details.):

4. a) ny past addictions to obacco, lcohol or r s (If yes, please i e details) : No ✔ Yes

b) ny c rrent se of obacco, lcohol or r s ( pecify bstance, re ency and last se) No ✔ Yes

5. For women applicants: If Pre nant, please indicate which month ( ote: e to limited medical facilities
nearby, we can only accept those applicants who are in the t to t mont of pre nancy):

6. o yo ha e any past/present experience with eiki, spirit al healing or any other meditation No Yes ✔
practices? If yes, please give details:
I have practice Vipassana meditation at home

I hereby agree to set aside all past spiritual/religious practices, rites , rituals, recitation, fasting and prayers as well as
any religious or spiritual objects for 10-days. All reading, writing material, mobile phones etc. should be deposited at
the Course Office for 10-days.
I acknowledge that I have carefully read and understood the Code of Discipline for Meditation Courses. I agree to stay
on the course site and to abide by all the rules and regulations for the full 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 fully understand that the Center does not have any medical facility and thereby the management will not be liable for
the consequences arising out of any illness during the period of the course. I am joining this course on my own free will.
I hereby certify that the above information is true to the best of my knowledge.
In addition, I hereby consent to the storage and handling on a computer or otherwise of my above stated
personally identifiable information in accordance with the Privacy Policy of the facility at which the course is
being held.

Signature Date 2023-06-21