E-Vam Buddhist Institute
                               Program Registration Form
						 
Your name: ............................................................................... Date: ....................

Principle Address: .....................................................................................................

................................................................. Zip code:................................................

Principle Contact Phone No .......................................................................................

E-mail address: ........................................................................................................


Title of course: .........................................................................................................
Day arriving: ............................................. Day leaving: ...........................................


Please check one: 

____E-Vam member  ____Associate  ____Full  ____Family  ____Sustaining

____Not a member


____Staying at E-Vam  ____Shared room  ____Dormitory 

____Commuting


Deposit 50% of the cost of the course is required for registration.


Mode of payment:

____enclosed is my check/money order for $ ..................

Please make your checks payable to: E-Vam Buddhist Institute


____credit card ____debit card (visa or master card only) $ ..................

Credit card number: .................................................................... Exp.date ___/___

Name on account: ...................................................................................................

Billing address: ........................................................................................................

.................................................................. Zip code:...............................................

Signature ................................................................................................................



Please send the registration form with deposit to:

E-Vam Buddhist Institute
Program Registration
171 Water Street
Chatham, NY 12037