One Day Application Form

Dhamma Java (Old Student Only The Sadhana Office Space Jl. Lavionda Raya no. 30-31 BSD City Tangerang Selatan, Banten Tempat Bu Wei Wei HP: 0812-9555-3339) - 10th Nov, 2024

Have you completed a 10-day course with S.N. Goenka or any of his assistant teachers?

Yes

This course is only for students who have completed atleast one 10-day Vipassana course

Old Student Section

Please choose what you are applying to do

Attend the course

Serve the course

Gender

First Name

Last Name

Photo ID Type

ID Number

Date of Birth (YYYY-MM-DD)

Address

City

Zip / Postal / Pin Code

Country / State

Mobile Number

Prefix your country code. For eg +91 for India.
Space, Comma, Dash(-) not allowed.

Emergency Contact Name

Emergency Contact Number

Prefix your country code. For eg +91 for India.
Space, Comma, Dash(-) not allowed.

Date of Last course (YYYY-MM-DD)

Location of Last course

No. of 10 Day Courses

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

By checking the box below, I acknowledge and agree that any and all information provided in this application for acceptance into a Vipassana Meditation course, or otherwise provided by me to the Vipassana organizations, may be used by the Vipassana organizations for their purposes consistent with their Privacy Policies, as amended from time to time.