Name 姓名:

Sex 性別:

Nationality 籍貫:

Passport No. 身份證字號:

Date of Birth 出生日期:

Status – Monastic □Bhiksu □Bhiksuni □ Sramanera   □ Srameneri         

Lay      □Three refugees 三皈依  □Five precepts五戒  □Bodhisattva precepts菩薩戒

Marital Status 婚姻狀況: □Married 已婚 □Unmarried 未婚 □Married Single 已婚單身

Education 學歷:

Profession 經歷:

Special Skills 專長:

Do you have any health Problem? 健康狀況 

□None 沒有       □High Blood Pressure 高血壓   □Heart Problem 心藏病  

□Diabetes 糖尿病  □Asthma 氣喘   □Other 其他:

Mailing Address通訊地址:

Phone 電話:                   FAX 傳真:                   E-mail:

Beeper 呼叫器:                Cellular phone 行動電話:

I wish to participate in the following:

□Seven-day Amitabha Chanting Retreat (1^st to 7^th of every month),

  please indicate month: ___________ (請註明參加佛七的月份)

□Two-day Weekend Retreat from__________ to __________ (please indicate date)

   請註明參加假日修道會的日期

Have you participated in any chanting retreat?

□ First timer in seven-day chanting retreat 第一次參加佛七修道

□ First timer participated in two-day retreat第一次參加週未念佛

□ Have participated in the 49 days Chanting Retreat曾參加七七四十九天念佛修道

□ Have participated the Seven-day Chanting Retreat for ________ times曾參加____佛七次數

I shall abide by the rules and regulations of the Amitabha Chanting Hall during the retreat period.

                  Signature:                                    Date:

Please provide one

passport-size

photo

Comment by the person recommending 受理單位意見:

Remarks by the retreat organizer

主辦單位審核: