Recruiter Branch# Budget Assignment Start Date Assignment End Date Traveler Name Accommodations:ApartmentExtended Stay
Move-In Date Move Out Date
Hospital Name Hospital Address Shifts: DaysNightsBoth
Utilities in Employee’s Name? YesNo Max. Distance Willing to Travel Car? YesNo
Pets? YesNo How Many? What Kind? DogCat Breed # of Pounds Other
Nurse Traveling Alone? YesNo # Of Others Traveling with Nurse Relation to Employee Name and DOB of each additional Traveler
Is the traveler willing to work with Air BnB? YesNo # of Bedrooms Studio12*Other *Cost of 2nd bedroom will be charged to the traveler Need Furniture YesNo Floor Preference BottomTopNo Preference Difficulty with Stairs - Requires Elevator YesNo Smoker YesNo Additional Comments Standard Furniture Package YesNo Bed Type 1 Bed - QueenKing*Twin Beds* *Will cost more Extras Needed? TVMicrowave Rental Unit Amenities - Washer & Dryer - not always available YesNo Facility Amenities Fitness FacilityPool Will do our best to accommodate certain amenities. Might not be available in all areas. Special Requests - i.e. Housewares, etc. Date Submitted