Hillbrow Health & Wellbeing

Hillbrow Health & Wellbeing

Application for Hire Form
Booking Details
Room(s) required:

Other
Date(s) required:
Times from and to required (inclusive of set up and take down times):
Purpose of Function:
Miscellaneous Equipment/Facilities required:
Estimated Numbers Attending:
Catering/Bar Requirements (if applicable):
Your Details
Name of Organisation or Club:
Are you a charity?
Your registered charity number
Does your service carry out CQC Regulated Activities?
Please upload your certificate of CQC Registration

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Are you and NHS Provider?
What is the name of the NHS Trust?
Name

First NameLast Name
Address

Street Address

Street Address Line 2

Local AreaCounty

Post Code
Email
example@example.com
Phone Number
Please enter a valid phone number.Format: 00000000000.
Purchase order number (if applicable):
Are the details above the same for invoice?
Name For Invoice

First NameLast Name
Email for invoice
example@example.com
Address for invoice

Street Address

Street Address Line 2

Local AreaCounty

Post Code
Phone Number for invoice
Please enter a valid phone number.Format: 00000000000.
Please upload your Public Liability insurance Document below.

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Declaration

The applicant should not infer that by the submission of this application form the booking will be accepted.
Signature
Booking added to Gladstone
Intact account no.
Date invoiced

MonthDayYear
Date
Payment received

MonthDayYear
Date
Should be Empty:

Booking Details