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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

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