Angthong International Meditation Center

65/6 Moo 7 Champa Lo, Mueang Ang Thong, Ang Thong 14000
paaukthailand@gmail.com

Application Form

(NOTED : PLEASE FILL UP ALL THE INFORMATION IN ENGLISH)

First name *
Last name *
PASSPORT NUMBER *
PASSPORT EXPIRY DATE *
NATIONALITY
COUNTRY
SEX *
AGE *
DATE OF BIRTH *
PLACE OF BIRTH *
RELIGION *
RESIDENCE ADDRESS (HOME) *
PURPOSE OF VISITING OUR CENTER *
PERSONAL CONTACT
MOBILE *
Email *
CIVIL STATUS *

EMERGENCY CONTACT PERSON (MUST BE FAMILY RELATIONSHIP)

NAME *
TEL *
RELATIONSHIP *
DATE OF ARRIVAL IN THAILAND *
DATE OF ARRIVAL IN OUR CENTER *
HAVE YOU SUFFERED FROM ANY LONG-TERM PHYSICAL ILLNESS WITHIN THE PAST 3 YEARS? (E.G. KNEE PROBLEMS, EPILEPSY, HEART PROBLEMS, BACK PROBLEMS ETC.) *
HAVE YOU TAKEN ANY MEDICATION FOR THE PHYSICAL ILLNESS (ES) WITHIN THE LAST 3 YEARS? *
HAVE YOU SUFFERED FROM ANY MENTAL ILLNESS WITHIN THE LAST 3 YEARS? (E.G. DEPRESSION, PSYCHOSIS, OBSESSIVE COMPULSIVE DISORDERS AN ETC.) *
HAVE YOU TAKEN ANY MEDICATION FOR THE MENTAL ILLNESS (ES) WITHIN THE LAST 3 YEARS? *
HAVE USED ANY ALCOHOL, DRUG AND/OR OTHER INTOXICANT WITHIN THE LAST THREE YEARS? *
HAVE YOU HAD A CRIMINAL RECORD ISSUED TO YOU WITHIN THE LAST 3 YEARS? *
HOW LONG HAVE YOU BEEN MEDITATING FOR AND WHAT TYPE OF MEDITATION HAVE YOU BEEN PRACTICING (E.G. MINDFULNESS OF BREATHING, METTA, MAHAYANA PRACTICE, GOENKA, MAHASI ETC)? *
HAVE YOU VISITED OUR CENTER BEFORE? IF YES, PLEASE INDICATE THE DATE AND PERIOD STAYED *
HOW LONG DO YOU INTENT TO STAY IN OUR CENTER? *
REFERENCE PERSON’S NAME *
OCCUPATION *
CONTACT NUMBER *
AGREEMENT *