D•msevkþAš kþA pircy p©
Introductory Form For Dhamma Servers
For Office use only:
ID No.
Course Date:
Remark
Personal Information:
PHOTO
/ Full Name
R / Age
/ Male 
/ Female 
/ Education
/ Home Address
/ Pin Code
/ Tel. No. (with STD code)
Email:
Occupation (Present / Past)
/ Name of Company
/ Department
/ Designation
/ Any physical or mental illness,
/ in the past
at present
Course and Dhamma Service Details:
/ No. of courses
10
STP
20
10-Spl.
/
First Course Date, Place
30
45
60
/
Last Course Date, Place
Regular daily practice of Vipassana meditation is defined as two one-hour sittings, morning and
evening each day. Since how long have you been practising Vipassana regularly?
years


Have you been practising any other meditation such as Reiki / Spiritual healing in the past or at
present?
Yes  No 
If yes, then give details:
No. of courses served
Give details of the service you have given, mentioning the most recent service first.
/ Date
Centre Name, City
Type of service
/ Do you have any of the following skills?


/ Typing

/ Office Work
/ Plumbing

/ Gardening
/ Other skills (specify)


/ Computer
/ Electrical
/ Planned duration of stay
Do you have the consent of your family members to stay here at this Centre?


Yes  No 
Give details of no. of courses your family members have attended
/
Short personal introduction : Family / social background, State of mind

During the past year have you maintained the Five Precepts
without breaking them in any major way?
If no, then give details:
/ in the past

Yes  No 
Any addictions (drugs/alcohol/tobacco/etc.):
at present
Please provide contact details of an Assistant Teacher/ Trustee/ Course Manager/ Centre Manager
in your area who knows you well.
Name__________________________________________
City__________________
/ Tel. No. (with STD code)
Have you read the Code of Discipline for Dhamma Servers?


Yes  No 
mÓ jbtkþ kšþdR pr hUÙ tbtkþ pAÙcAš ÕIlAš kþA pUfQ Áp se pAln kþrnA merA wHrdAiyØv hÔ¦ glityAÙ ho skþtI hÔ, iPþr BI, Sgr
muJse ikþsI BI akþ ÕIl kþA bìze Áp mš w£lMGn hotA hÔ to mÓ wskeþ bAre mš kšþdR pr wpV‰Tt ikþsI akþ shAykþ SAcAyQ kþo pUfQ
ivvrf keþ sAT btAWMgA¦ qskeþ sAT-sAT kšþdR keþ SnuÕAsn kþA pAln kþrnA BI merA wHrdAiyØv hÔ¦ Sgr mÓ qskþA pAln kþrne
mš SsPþl rhtA hUÙ to ¯yv‰TApn wict infQy lete hua ibnA ikþsI ‰pÏxIkþrf keþ muJe kšþdR Coìzne keþ ila kþh skþtA hÔ¦
While at the Centre, I undertake to strive with utmost sincerity to follow the Five Precepts. Mistakes
can occur. However, if I break any of the precepts in a major way, I will immediately inform an AT at
the Centre giving full details. Further, I undertake to follow the code of discipline of the Centre. The
management may take appropriate action if I fail to do so at any point, even directing me to leave
the Centre without offering any explanation.
/ Date
/ Signature
18 March 2015, (5, 000 copies)