To : Jimmy Quek
Blk 286 #07-171,
Tampines Street 22 S’pore(520286)
Email :
Application Form
1-8 May 2005 Vipassana Meditation Retreat
from______to ______
Leaving ( ) before breakfast ( ) after breakfast ( ) after Lunch
Name: ______Age: ______Sex: ( )Female ( )Male
Address: ______
______Postal Code: ______
Contact No: Tel/ Hp/Pager ______Email: ______
Identity Card No: (Blue/ Red*) ______Expiry Date (for Blue I/C) ______
· Passport No & Expiry Date : ______
· Visa or Work Permit No & Expiry Date : ______
(Please present the above-mentioned original documents for verification.)
Are you new to Vipassana Meditation? Yes ( ) No ( )
If “No”, please specify the type(s) and teacher(s): ______
______
Medium of Instruction preferred: ( ) Burmese ( ) English ( ) Mandarin
Any history of mental abnormality ? ( ) Yes ( ) No On treatment : ( ) Yes ( ) No
If Yes, diagnosis ______Date of last Review: ______
Next of kin to be contacted in case of emergency. Name: ______Relationship: ______
Address: ______Contact No: ______
I, ______, the undersigned declare that the above information is true and am willing to abide by the meditation instructor's advice and retreat regulations. Otherwise I will leave on my own accord. I also understand VMC and Management Committee/owner of the retreat venue will not be responsible for any mental or physical injury, losses, damage of whatsoever nature incurred by me during the retreat.
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Applicant Signature Date
· for Non -Singaporean applicant only
( ) I am already on the emailing/ list
( ) Pls put me on your emailing/ postal mailing list
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Deadline : 24 April 05 (Sun)
(Priority will be given to Full Timers)
Pls email Bee Wee at or SMS via 96315732 if you can help as dhamma workers or contribute towards the meal dana (monentary or/and in kinds)