You may take photocopy (xerox) of this form as per your requirement

Vipassana Meditation onf

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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 2021-11-27 To 2021-12-05 Center: Dhamma Ajaya, Chandra

First Name Name Last Name ( rname)

Arti Haridas Patil Gender:
Male
Address (with ity, ist , o ntry etc ):
Ganesh nagar,war no.3,wardha, Wardha, MH, IN Female ✔
Date of Birth
(dd/mm/yyyy):
Pin code: 442105
29 05 /______
_ _ / ___ 1990
Contact Home: 918830389406 Mobile: 8830389406
Detai s Work: 918830389406 mail: Artipatilpatil971@gmail.com Age - 31

1. P Passport ✔ adhar ard P ard National ID 270861273778

(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: B.A, D.ed tution classes

3. Name Of Organization: Nhi Nhi

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

If yes, write Name and relationship No Yes ✔
Rekha patilâ•’ aai haridas patilâ•’ baba bhupesh patil
- bhau shubhan
5. U
Shubhangi thool(Bahin) - 919822528953
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 1RQH Basic Intermediate Expert
1RQH Basic Intermediate Expert
Preferred language of Instructions/Discourses: Marathi 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 __________________
2017-2- Location _____________________
Tapobhumi Amboda,dist Teacher(s)
wardhaChinchkhede madam

2. Most Recent Course (Sat): Date ______________

2020-12- Location ________________ Teacher(s)
Ajaypur vipassana Shirsagar
ceter,dist sir
chandrapur

3. -day P pecial o rse -day -day -day -day eacher s self co rse hamma er ice
4 0 0 0 0 0 0 0 1

. Have you maintained your practice of Vipassana meditation since your last course? No Yes ✔
If yes, please give details (how much time daily, etc.). Sakali 1 tass ani sandhyakali 1 tas

DG/INF/IT/COMP/01/10-day_app_v -F . 201 .pdf For information on Vipassana: http://www.dhamma.org

 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 ):

. 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

. 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):

. 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 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 2021-11-27

DG/INF/IT/COMP/01/10-day_app_v -F . 201 .pdf For information on Vipassana: http://www.dhamma.org