eRideable Shelter Access Application form

eRideable Shelter Access application

For Queen Elizabeth II Medical Centre (QEIIMC) Campus Staff
Please complete this form if you wish to apply for access to the eRideable shelter located at the eastern end of Car Park 7.

This shelter is managed by the QEIIMC Trust and facilitated by North Metropolitan Health Service (NMHS). The facility is available to staff working at QEIIMC Campus only.

If you are non-NMHS staff, you will be issued a physical access card to use the shelter.
Personal Details
Name*

First NameLast Name
HE number (if applicable)
Position Title*
Department*
Organisation*
Phone number

Area CodePhone Number
Email address*
example@example.com
Frequency of intended shelter use*

1-2 days per week3-5 days per weekA few times a month/occasionallySeasonal/weather dependant onlyShift worker (AM)Shift worker (PM)Not applicable
Parking status*

Permit holderNone

eRideable information
It is essential to understand and comply with the policy requirements. This will help ensure your products are safe and meet regulatory requirements:
- An E-Bike means a bicycle that: contains or is powered by a rechargeable lithium battery.
- An E-Scooter means a scooter that: contains or is powered by a rechargeable lithium battery.
Type of eRideable*

E-BikeE-Scooter
Make*
Model*
Registration number (serial number)*
Colour / Identifying features
Reason for application*

Terms and Conditions
By signing this form, you acknowledge and agree to the following:
- I acknowledge that this application is for access to the QEIIMC eRideable Storage Facility located in Car Park 7 for storing an eRideable device.
- I agree the shelter is for the duration of my shift and short-term storage only.
- I understand issuing the access does not guarantee availability of a parking space and that the facility may not be available from time to time.
- I agree to park in a designated rack space, not blocking access or other users’ eRideables.
- I agree to use an appropriate lock and use it in the intended manner.
- I agree to abide by the Queen Elizabeth II Medical Centre (Delegated Site) By-laws 1986 as amended.
- The QEIIMC Trust accept no liability for the loss of, or damage to eRideables parked in any facility operated, owned or managed on the QEIIMC Campus.
- I agree to inform the QEIIMC TravelSmart Department of any changes to the information provided on this form. I understand that failure to inform the QEIIMC TravelSmart Department may result in the revocation of my access.
- I understand that access must not be shared, and that the QEIIMC Trust reserves the right to withdraw my access for misuse or violation of the QEIIMC eRideable Policy.
- If you have not accessed the shelter for a period of 3 months or longer, QEIIMC Trust reserves the right to terminate your access.
Terms and conditions*

I agree to the above terms and conditions
Declaration
I declare that the information provided in this application is true and correct to the best of my knowledge.
Signature*

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Date*

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Date
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eRideable Shelter Access application

Personal Details

eRideable information

Terms and Conditions

Declaration