Please complete the application below. You may attach additional information to this form as necessary. You may attach a copy of your resume if you wish.

Please mail your application to:

Dialogue House Associates
2155 Ocean Avenue - Suite C
Ronkonkoma, N.Y. 11779

Advanced Studies Program Application

    Date____________

Name_______________________________________

Address_____________________________________

City ______________State____ Zip code___________

Telephone   Day____________ Evening_____________

E-mail _______________________________________

Best time and place to call ________________________

List your educational experience (include any part-time or non-degree study).

List your employment history with the most recent positions first.

D. Intensive Journal Workshops Attended

List below the Intensive Journal workshops that you have attended. Please list no more than 10 programs (a workshop series of back-to-back workshops is one program). If you do not remember the specific dates and places, please describe as best you can. Use the back of this sheet if necessary.

E. Other Interests and Activities

List other interests and activities relevant to your interest in the Advanced Studies Program.

Write a brief essay (maximum of two pages) that summarizes

- your interest in Dr. Progoff's work;

- your reason(s) for applying for admission for admission to the Advanced Studies Program;

- how you use the Intensive Journal method in your own life and how it has affected your life. (Please provide specific examples.);

- how you intend to use your knowledge from this Program;

- why you will be a reliable and accountable representative of Dialogue House.

Provide the attached reference form to the leader who will complete and send it directly to Dialogue House Associates.

If you do not know a leader, please contact Jonathan Progoff to discuss your situation.

Please provide any other pertinent information for your application.

Please mail your application to: Jonathan Progoff, Dialogue House Associates, 799 Broadway, Suite 410, New York, NY 10003.

If you are accepted in the program, you can then submit the applicable fees. Thank you for your cooperation.

Please describe the candidate's qualifications for admittance into the Advance Studies Program for the purpose of becoming a certified leader. (You may attach a typed letter.) Please do not complete this form unless you know the person in depth. Thank you for your assistance.

Name of candidate___________________________________

E. Comments____________________________________

_______________________________________________

 Date____________