Application Form | Lumbini Golden Pagoda

Name

Phone*

State

City*

Country*

Gender*

Men

Women

Student*

Old Student

New Student

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

Yes

No

Photo i.d*

Pan Card

Aadhar Card

Voter i.d

i.d Number*

Name of Institution*

Father's/Husband's Occupation

Marital Status*

Married

UnMarried

Widow/Widower

Divorced

Are any of your friends or relatives joining this course? If yes, write their names and relationship

Yes

No

In case of emergency, whom to contact, please give their name and phone number (write your and their relationship)*

Language Knowledge: This course will be conducted in English Hindi. How much do you know them? Please inform which langueges you understand well.

English

Hindi

What is your Mother tounge

Does the Monthly Magzine 'Vipassana' come to your family?

Yes

No

Do you want the 'Vipassana Magzine' to be sent to you by email or post? please tick

Post

Email

1. First course Date, Place: Conducting Teacher:

2. Last course Date, Place: Conducting Teacher:

Please Enter Your Email i.d*

For Old Student ( details of courses done in this tradition)