World Dharma Retreat
Online Application Form
Maui, Jan 7 – 11, 2015

Name

Address

City

State/Provence

Country

Zip / Postal

Tel

Email

Website

Nationality

Passport valid though 2015?  Yes No

Livelihood

How did you learn about the retreat? And are you registered in our online Course through WDOI?

Please explain in a sentence or two why you wish to attend the retreat.

Please list any previous retreats with Alan (if more than two, the last two only):

Please list any special needs that you may have during the retreat.

How will you pay for the retreat? Pay Pal? Credit Card? Check? Other?

If you need a personal payment plan, what is the best plan for you?

Name and phone contact in case of emergency


Please allow 24 hours to look over your application.