Application for Mindfulness Trainings transmission

(Please print clearly)

        
			  Name
				
			  Phone
			  
			  Full address (including zipcode)
			  
Birthdate (dd/mm/yy)
GenderMale Female
Five Mindfulness Trainings 
Dharma Name / Monastic Dharma Name
Requesting transmission of
 which mindfulness training?
Request of 14 mindfulness
 trainings supported by which 
sangha or dharma teacher?
				
			  Have taken which mindfulness trainings?With whom?When? (dd/mm/yy)Where?

			  1.
			  
			  2.
			  
			  3.
			  
			  4.
			  
Here are my aspiration and comments (continue on back if needed
For office use only

			  Application received by whom?
			  
			  Dharma name given
			  
Date and place received?
			  
Date of Transmission (d/m/y>?
			  
			  Certificate handed / sent (d/m/y)
			  
By whom?
			  
			  By whom?
			  
In name of
			  
			  Other information:
			  
Location of transmission:

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Application for Mindfulness Trainings transmission

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