Fo Guang Shan Hsi Lai Temple Taking Refuge - Registration

    English Name:      Chinese Name:  

    Gender: Male    Female                         Date of Birth:

    Nationality:

     Address:

    Telephone:  Home        Office       Fax

               Cell Phone        E-Mail

    Education:

    Occupation:    

    Language Used:   Chinese    English    Cantonese     Other

    Reasons for Taking Refuge:  
   

    Member of BLIA?: Yes    No                         BLIA Subchapter: