Application Form

DhammaJava

Have you completed a 10-day course with S.N. Goenka or any of his assistant teachers?*
Yes	No

How many times have you completed the 10 days course? *

Gender*
Male
Female

Please choose what you are applying to do*
Attend the course
Serve the course

Firstname*	Lastname*

ID Number*	Upload Photo
	Max file size 2MB

Age*	Date of Birth*

Country*

Region*

-- Select Your Country -- Indonesia

-- Select Your Region -- Aceh Bali Bangka Belitung Islands Banten Bengkulu Central Java Central Kalimantan Central Sulawesi East Java East Kalimantan East Nusa Tenggara Gorontalo Jakarta Jambi Kalimantan Lampung Lesser Sunda Islands Maluku Maluku Islands North Kalimantan North Maluku North Sulawesi North Sumatra Papua Riau Riau Islands South Kalimantan South Sulawesi South Sumatra Southeast Sulawesi Special Region of Yogyakarta Sulawesi Sumatra West Java West Nusa Tenggara West Papua West Sulawesi West Sumatra

Address*	City*
	ZIP / Postal / Pin Code

Primary Language*	Profiency Level*
	-- None -- Beginer Intermediate Expert

Indonesian Profiency	English Profiency
-- None -- Beginer Intermediate Expert	-- None -- Beginer Intermediate Expert

Email*

Mobile Number*	Home Phone	Work Phone
+	+	+

Education	Occupation

Company Name	Departement	Company Designation

Emergency Contact Name*	Emergency Phone*	Emergency Contact Relationship to You*
	+	-- None -- Mother(Ibu) Father(Ayah) Brother(Saudara Laki) Sister(Saudara Perempuan) Husband(Suami) Wife(Istri) Child(Anak) Friend(Teman)

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?*
Yes
No

Do you have any physical health problems, medical conditions or diseases?*
Yes
No

Do you have, or have you ever had, any mental health problems such as significant depression or anxiety, panic attacks, manic depression, schizophrenia, etc.?*
Yes
No

Are you now taking, or have you taken within the past two years, any prescribed medication?*
Yes
No

Are you now taking, or have you taken within the past two years, any alcohol or drugs (such as marijuana, amphetamines, barbiturates, cocaine, heroin, or other intoxicants) or mind-altering plants and substances (such as ayahuasca, peyote, LSD, etc.)*
Yes
No

Will a friend or family member be taking this course as well?*
Yes
No

Yes, I accept the terms of the Privacy Policy and the other terms of submission of this application form.*