100 Million Mani Retreat Registration Form

Step 1. Fill out the form and send

Personal Details

First Name* Last Name*

Birth Date* (Y/M/D) Gender*  Male Female

Contact Details

Email Address* Telephone*

Address*

Country* Language*

Emergency Contact Details

Name* Telephone*(incl. country code)

Ordination Details

Ordained monk/nun Ordained Name

Date of Ordination (Y/M/D) Level of Ordination

Previous Dharma Experience:

Have you attended Buddhist teachings before?*

 YES NO

Are you a regular visitor or member at a Buddhist centre?*
 YES NO

If so, which one?

Have you completed a long retreat before?*

 YES NO

If yes, how long?

Health Details

Please indicate any illnesses, medical conditions, allergies or injuries we need to be aware of;

Do you take any medications which the retreat organizers need to know about in the event of a medical emergency?*

 YES NO

If yes, please give details

Do you have or have you ever had any mental illness requiring medication, hospitalization or psychiatric counseling?*

 YES NO

If yes, please give details

Seating Requirements:

Do you need a meditation cushion?*  YES NO

Do you need a chair?*  YES NO

Volunteer skills at the retreat:

Could you please indicate if you have any skills that may be useful to contribute
to the retreat

Attendance at Retreat:

If not attending for full retreat, please indicate start and finish date of attendance.

Star: Finish:

Declaration *

I accept that the retreat organizers will call an ambulance should it be deemed I need medical attention and I accept that I shall be liable for any expenses incurred.

I have truthfully provided all the information asked of me on this form and hereby undertake to absolve FPMT Mongolia or any individual office holder from any legal or financial responsibility I may incur while attending the retreat

I acknowledge that I have read and understood this form and declaration:

Signed:

Retreat Cost: (includes attendance at retreat and lunch each day)
Sweet rice or bread together with tea, will be served each morning;

Please note: There will be a 10% discount on the Retreat cost if paid in full by or on 30th April, 2013.

Four weeks (Full Retreat) ----> USD 900 ----> less 10% = USD 810
Three weeks (21 days) ---> USD 790 ---> less 10% = USD 711
Two weeks (14 days) ---> USD 520 ---> less 10% = USD 468
One week (7 days) ----> USD 300 ---> less 10% = USD 270

Retreat Supplies

Retreat book - English $19 (Note: If you have the 2009 edition, please bring with you) YES NO

Retreat cushion $6  YES NO

Transport - Airport to City and return

Transport from the airport $10 YES NO

Arrival date/time and flight number

Transport to the airport $10 YES NO

Departure date/time and flight number

I wish to sponsor a Sangha member or Other USD

Full amount to be paid in USD (inclusive of Retreat cost, retreat supplies, transport and Sangha sponsorship) = USD

If not paying in full, a deposit of 50% of the above total is to be paid with the reservation = USD

In the event of your needing to cancel, a 5% administration fee of the total amount paid will be deducted, together with the bank charge to process the refund.

2 Payment options:

1. See Secure Payment below;

2. Bank Cheque, International Bank Draft, International Money Transfer to:

Beneficiary: FPMT MONGOLIA
Account No: 499066687 (USD)
Bank:    TRADE AND
DEVELOPMENT BANK OF MONGOLIA.
ULAANBAATAR, MONGOLIA
Swift Code:   TDBMMNUB

please send an email with your name and payment amount to: mani@fpmtmongolia.org

Step 2. Secure Payment

Go to Our Secure Online Payment Page (128bit)

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