ACCOMMODATION BOOKING FORM

* Please note that yellow fields are mandatory

Location required
Is this form an amendment to an existing booking?

If yes, please state changes you are making. E.g. Start date, accommodation type
If yes, please state start date of original booking
AGENCY DETAILS (If appropriate)
Agency Name
Name of Booking Agency Contact
Booking Agency Telephone Number
Booking Agency Email
APPLICANT DETAILS
Title

First name

First name
Last name
Please state here if known by any other name
Date of Birth
Gender
Ethnic Origin
National Insurance No
GMC/UKCC No

Job Title
CONTACT DETAILS

Correspondence Address (including postcode)

Telephone
Alternative telephone
Email Address
ACCOMMODATION REQUIREMENTS
Accommodation Type
How many adults?
How many children?
First night of stay
Last night of stay
Any additional requests or preferences?
STATEMENT 1 - ULHT Status
Are you employed by, about to be employed by, work within, or undertake training with
United Lincolnshire Hospital Trust or deliver healthcare services on behalf of the Trust
at any location?

Date of Birth
Gender

Junior
doctors2on
a deanery programme
who are able to provide evidence of a
STATEMENT
- Mortgage/Rent
Commitments
mortgage or tenancy agreement during their employment with ULHT will be assisted
with 3* single accommodation costs or excess travel. Assistance is only provided to
individuals on the basis that they do not sublet the property in question at any point
during the duration of their employment with the Trust. All accommodation is allocated
on a first come, first serve basis. If you choose to rent from a provider other than
Progress Living please be aware that no assistance will be given. Please note that you
must provide documentary evidence of your continuing commitments at the same time
as applying for accommodation and this evidence should be sent to the Medical
Recruitment Team. If you do not provide evidence, your booking form will NOT be
authorised for Trust paying and you will be liable for all rental charges.
If you wish to claim for either of the above, please complete the claim form available
from the Medical Recruitment Team and enclose a copy of your mortgage/tenancy
agreement and evidence of your most recent payment e.g. bank statement/receipt.
Please note that you must provide documentary evidence of your continuing
commitments at the same time as your completed booking form, if you are unable to do
so you must submit your documents within 2 weeks of your commencement date. If you
do not provide evidence, your booking form will be submitted detailing that you are
liable for all rental charges.
Please note medical students are entitled to
standard 1 bed shared accommodation for the duration of their placement, this
will be paid for by the Trust.
Please select the appropriate statement.
STATEMENT 3 - Schedule One
Are you related to a member of staff or Board member of Progress Housing Group, or
to a former member of staff or former Board Member of Progress Housing Group? (If
yes, please give details)
If yes, please give details

STATEMENT 5 - PD11
If the Trust is responsible for the payment of any part of your rent this is a potential tax
liability (benefit-in-kind) to the applicant/employee, which must be reported to the H M
Revenue & Customs by the Trust. This will then be reported in the form of an annual
P11D return, a copy of which you will also receive.
I have read this statement.
STATEMENT 6 - Data Protection

In connection with the accommodation provided to me by Progress Housing Group (the

Accommodation) I hereby irrevocably consent to the provision by United Lincolnshire
NHS Trust to Progress Housing Group of my forwarding address and other contact
information, and to the use of that address and other information by Progress Housing
Group and its authorised agents for the purpose of securing payment of any and all
sums due from me in connection with the Accommodation. I understand and agree that
this consent will remain effective after I have left the Accommodation.
Do you agree to these terms and conditions
OFFICE USE ONLY
Date application received from customer
Date processed
Validation Checks Undertaken?

Referral Code
First night that accommodation will be paid for by Trust
Last night accommodation will be paid for by the Trust
Is rent to be charged to tenant (Please enter YES if the tenant does not qualify for rent payable by the Trust)
Applicant Speciality
Department
Business Unit Manager
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