APPLICATION FOR THE YEAR 2007 RETREAT

Name (Exactly as it appears on your passport)________________________________
Sex: Female______ Male________
Address_____________________________________________________________________
City _____________________________State_____ Zip Code ___________ Country____
Phone ( )________________________________
Email:________________________________
Date of Birth ________________________________________________
Passport No.__________________________________________________
Country on Passport _________________________________________________________
Occupation:__________________________________________________________________
Emergency Contact:
Name __________________________________Relationship___________________________

Address ____________________________________________________________________
Phone ( )__________________________Email__________________________________

If you have attended meditation retreats in the Theravadan tradition please
list them below
Date Teacher Location Length of retreat

Please list any other meditation traditions you have practiced in the last 5 years.

Please be thorough and honest in your answers to the questions below so that the
Sayadaws can most skillfully guide your practice.

1. Do you have any history of physical illness, limitations or special needs,
which might affect your stay in Burma, or an illness that requires constant
treatment? If so, please be specific.

2. Are you currently taking any drugs or medications? Please list each
medication and the condition being treated.

3. Have you ever been diagnosed with a psychological condition? Please describe
the diagnosis, treatment given, (including medications), and the dates.

4. Have you ever experienced or been treated for moderate or severe depression
or a nervous breakdown? If yes, please list the date(s). Has the condition been
resolved ?

5. Have you ever attempted to take your life? Yes______ No_______
If yes, please describe the circumstances and dates.

6. What is your purpose in wanting to participate in this retreat? State your purpose clearly.

PLEASE READ CAREFULLY AND SIGN BELOW:

I hereby certify that all of the information contained in this application is
complete and accurate to the best of my knowledge. I understand that, if
accepted, omissions or false statements on this application shall be considered
sufficient cause for dismissal. I will not hold Panditarama responsible for any
liability during my travel or stay for this retreat.

_____________________________________________ _____________________________
Signature of applicant Date signed