Accommodation Enquiry Form

Accommodation Enquiry Form

Welcome to our Health Service! This form is for Staff of Robinvale District Health Services requiring short/long term Accommodation.
Full Name:*

First NameLast Name
Email Address:*
example@example.com
Phone Number:*
Please enter a valid phone number.Format: (000) 000-0000.
Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Campus:*
Please Choose below:*
Department:*
i.e Nursing, Physiotherapy
Short Term (4 weeks or under)Long Term (Over 4 weeks)
Arrival Date:*

DayMonthYear
Date
Departure Date:*

MonthDayYear
Date
Will you have your own Vehicle?:*
YesNo
EFTPayroll Deduction
General Comments about your enquiry:
Signature:*

Clear
Once your enquiry form has been received, we will contact you via email shortly after.

Accommodation is subject to availability and is approved once the Accommodation Agreement has been signed.
Should be Empty: