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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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