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? YesNo

    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.