Oneness Experience Course Application

Oneness Awakening Course Application

Presented at The Center for Conscious Living Feb.18 & 19, 2012

Applicant’s Name

Street Address

City State Zip Code

Home phone Cell phone

Email address

Course Dates: February 18-19, 2012

Course Location: Center for Conscious Living, 302 N Washington St. 101E, Moorestown, NJ 08057

Course Fee (please check):

Method of Payment (please check)

____$ 150 if received before February 12^th

____$ 195 after February 12^th

____$ $50.00 (Oneness Blessing Givers only)

____ Cash

____ Check (payable to Center for Conscious Living)

____ Credit Card – MC, Visa or Am. Ex?_________

Card #________-__________-_________-________

Exp. MM/YY_ _ /_ _ Amount $__________________

1. Have you received the Oneness Blessing? _____

2. How did you hear about this course?

3. Are you currently using or have you used within the last 6 months any medications for any

mental health problem? _________

4. Have you ever been institutionalized for a mental health problem? _______________

5. Have you ever been diagnosed with a mental health problem? _____________

If so, please describe the problem:

6. Are you challenged by substance dependence or abuse? If so, which substances and how regularly

do you use them?

I hereby state that all of my answers to the questions contained in this application are true, correct and complete.

__________________________________

Applicant’s Signature

Please mail your application along with your payment to:

The Center for Conscious Living, 302 Washington St. #101E. Moorestown, NJ 08057