Commuter Program

1

**You must complete this form using GOOGLE CHROME as your browser as Microsoft browsers, ie Internet Explorer or Microsoft Edge, will not work**

2

Name* This field is required.

First Name

Last Name

3

Select your preferred check-in date and time* This field is required.

4

Select your preferred check-out date and time* This field is required.

5

Shift Working* This field is required.

Day

Night

Call

6

Will you need another stay?* This field is required.

YESNO

7

Select your preferred check-in date and time

8

Select your preferred check-out date and time

9

Shift Working

Day

Night

Call

10

Will you need another stay?

YESNO

11

Select your preferred check-in date and time

12

Select your preferred check-out date and time

13

Shift Working

Day

Night

Call

14

Will you need another stay?

YESNO

15

Select your preferred check-in date and time

16

Select your preferred check-out date and time

17

Shift Working

Day

Night

Call

18

Enter and confirm your Personal e-mail Address* This field is required.

example@example.com

19

Please provide any additional information we will need to consider when making your reservation.

20

I have fully read the Nurse Commuter Accommodation Policy* This field is required.

Yes