RC003 / 2013-03-20

SBS Retreat Centre

RECENT
PHOTO

Self-retreat Application Form

This form is to be completed by a yogi applying for the first time to do a self-retreat in
Ssanrakkha Buddhist Sanctuary Retreat Centre (SBSRC).
Please complete every box unless specified otherwise.
Referees name:

Important:The referee must be recognised by SBSRC,

and he/she must fill in a Letter of Reference (RC004) to
be submitted together with this form.

Telephone:
Full name (as in NRIC/Passport):

Sex: Female

Occupation:

Male
NRIC no:

Skills:

Date of birth (dd/mm/yy):

(For foreigners only)

Passport no.:

Nationality:

In case of emergency, contact

Name:

Passport expiry date:

Visa expiry date:

He/she is my

Address: residence correspondence

Telephone:

Email/Fax:

3
Telephone:

Name of Buddhist organisation associated with:

Telephone:

Email/Fax:

Past guided meditation retreats (See reply letter for details on the requirements.)
Teacher
Type

Duration

When (Year)

...

..

...

..

...

..

...

..

Have you had any significant mental health issue? If yes, please give details (dates, symptoms, duration, hospitalization,
treatment, and present condition).

No Yes

Do you have any significant physical health issue? If yes, please give details (symptoms, treatment, and present condition).

No Yes

Other information:

I hereby declare and acknowledge that:

I wish to stay in Ssanrakkha Buddhist Sanctuary (SBS) as a yogi observing the 8 precepts.
The particulars given in this form are to the best of my knowledge true and correct.
If allowed to stay in SBS, I shall abide by the rules and regulations for yogis laid down by the SBS
Management Committee (SBSMC).
I shall not hold SBSMC or SBS Sagha responsible for my conduct that is contrary to its rules and
regulations.
I shall not hold SBSMC or SBS Sagha liable for any mishap due to my own negligence during my
stay in SBS.
SBS reserves the absolute right, in exceptional circumstances, to require a resident to leave SBS
at 24 hours notice. This right shall be exercised in the best interests of SBS.
SIGNATURE

DATE

Submit this form by ONE

of these ways:
email
rc@sasanarakkha.org
fax 05-8411198
ordinary mail SBSRC
c/o Cheng Lee Shing,
15, Lrg Tasik Permai
6, Tmn Tasik Permai,
34000 Taiping

RC003 / 2013-03-20

Information Updates
Note: Please cross out outdated data in the relevant box on page 1.
No.

Particulars

Revised on

Yogis Signature

Stay-in Record (for office use only)

No.

Duration

Approved by

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