ASCII TEXT APPLICATION FORM FOR MEDITATION COURSE

Please Note that you cannot type on this form as it appears in your browser (Netscape or Internet Explorer).
You must first: (1) do a "save as" and save the file on your computer hard disk as "app.txt"; (2) start a
text processor application such as Windows Notepad; (3) open the saved "app.txt" file with Notepad and
type in your answers to the questions; (4) save the completed form again; and, finally, (5) either
print out the completed form and post it or fax it to the registration address/fax number
or fax it directly from your computer.

	To apply for a place on the course, please complete
this form, print and "sign it" and then mail or fax it to the 
Center at which the course for which you are applying is being conducted
and await confirmation. Please answer all questions fully. All information
will be kept strictly confidential. If you are unable to either print and
mail or fax this on-line application form, please contact the applicable
Center or Non-Center course location by phone, fax or E-Mail and request
an application form by mail.

CENTER OR OTHER COURSE LOCATION:___________;

COURSE DATES:(from)__________(to)__________;

TYPE OF COURSE (10 DAY, ETC.):________________________;

FIRST NAME:______________________________________;

LAST NAME:______________________________________;


ADDRESS (Street/P.O. Box):__________________________;

	(City):____________________________;

	(State/Prov. & Country):__________________;

	(Zip or Post Code):________________;

E-MAIL ADDRESS:____________________________;

TELEPHONE NUMBERS: (Work) (_____)___________;
		  (Home) (_____)___________;
		   (Fax) (_____)___________;

AGE: _____;

YEAR OF BIRTH: ________________;

MONTH OF BIRTH: ________________;

DAY OF BIRTH: ________________;

SEX:_____;

OCCUPATION:________________________________;

I am driving and willing to be contacted by other students seeking a ride to the course.  YES____;  NO____.


Will a friend or family member be taking this course as well? YES____;  NO____.

If yes, please state Name/Relationship: ______________________________________; 


Do You understand English very well?  YES____;  NO____;  If no, please explain (extent of English, native language, other languages).

Have you previously completed a 10-day course with S.N. Goenka or any of
his authorized assistant teachers?  NO____ (New Student);  YES____ (Old Student);

NEW STUDENTS:

1) Have you had any previous experience with meditation techniques, therapies, or healing practices? YES____; NO____.
If yes, please give details:

2) How did you learn about Vipassana, or who introduced you to this course?

	___Book/Magazine (which one? _______________);

	___News Article (which paper? ______________);

	___Poster (where? _____________);

	___Internet (which site? ______________);

	___Friend/Word of Mouth (name?______________);

	___Other (What? _________________);

	___Who introduced you? (_________________________).


OLD STUDENTS:

Please give following details:

FIRST COURSE INFORMATION:

DATE:_________________________;

LOCATION:_____________________;

TEACHER(S):___________________;

MOST RECENT COURSE INFORMATION:

DATE:_________________________;

LOCATION:_____________________;

TEACHER(S):___________________;

TOTAL NUMBER OF 10-DAY COURSES:

Sat Full Time: ____;

Served Full Time: ____;

Other courses sat (specify)_______________________;

Other courses served (specify)_____________________;

1) Have you practiced any other meditation techniques (including
other types of Vipassana), therapies or healing techniques since your last course with S.N.
Goenka or his assistant teachers?  NO____; YES____; If yes, please give details:



2) Have you maintained your practice of Vipassana Meditation 
since your last course? NO____; YES____; Please give details:


3) Would you be willing to come early to help with set-up if needed?  NO____; YES____.


4) Would you be willing to serve this course should the need arise?  NO____; YES____.


5) If you are not attending the entire course, please give your arrival date and hour: __________________;
							and departure date and hour:   __________________.	 

NEW AND OLD STUDENTS:

Do you have any physical health problems, medical conditions or diseases?  NO____; YES____.
If yes, please give details (dates, symptoms, duration, treatment, present condition).



Do you have or have you ever had any mental health problems such as, significant depression or
anxiety, panic attacks, manic depression, schizophrenia, etc.?
NO____; YES____.  If yes, please give details (dates, symptoms, duration, hospitalization, treatment, present condition).



Are you now taking, or have you taken within the last two years, any prescribed
medication? NO____; YES____. If yes, please give details (dates, types, dosage, present use).



Are you now taking, or have you taken within the last two years, any alcohol or drugs (such as,
marijuana, amphetamines, barbituates, cocaine, heroin, or other intoxicants)?
NO____; YES____. If yes, please give details (dates, types, amounts, addictions, treatment, present use).



	By completing the spaces set forth below with my name and the date, I hereby 
acknowledge that I have carefully read and understood the Code of Discipline for the 
Vipassana Meditation course for which I am applying.  I agree to stay on the course
site and to abide by all the rules and regulations for the 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 hereby
certify that the above information is true and correct to the best of my knowledge.

NAME: __________________________;

DATE: __________________________;

	Either print and mail or fax this document to the Center or Non-Center
course location at which the course for which you are applying is to be conducted.
If this on-line application cannot be sucessfully downloaded and completed, please
contact the applicable Center by phone, fax or E-Mail and request an application
form by mail.