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GNWT EE MTA Initial Request
GNWT Employee ID
*
MTA Approval #
Employee First Name
*
Employee Last Name
*
Employee Phone Number
*
Employee Email Address
*
Employee Home Community
*
Aklavik
Behchokǫ̀
Colville Lake
Deline
Dettah
Enterprise
Fort Good Hope
Fort Liard
Fort McPherson
Fort Providence
Fort Resolution
Fort Simpson
Fort Smith
Gamètì
Hay River
Inuvik
Jean Marie River
Kakisa
Łutsël K’é
N'Dilo
Nahanni Butte
Nahanni to Dehcho
Norman Wells
Paulatuk
Sachs Harbour
Sambaa K’e
Tsiigehtchic
Tuktoyaktuk
Tulita
Ulukhaktok
Wekweètì
Whatì
Wrigley
Yellowknife
Other
Employee Home Community
Travel Requested
*
Flight
Hotel
Ground Charter (for communities without a local airport, includes medical taxi, medical bus)
Air Charter (for communities without a local airport, includes helicopter, air charter)
Select "Flight" for commercial flights, "Hotel" for accommodations, and "Air Charter" or "Ground Charter" for communities that do not have an airport. This is not for regular taxi rides within Yellowknife or Edmonton to/from airport and appointment.
Number of Travelers
*
1
2
3
4
5
6
(If escorts are traveling from different communities or on different dates, please submit separate requests and add a note in the Flight Special Requests field.")
Do you have appointments in multiple destinations?
*
Yes
No
For example if you have a dental appointment in Yellowknife, and 2 days days later another specialist appointment in Edmonton
Return (Two-way) Trip or One-way Trip
*
Return Trip
Return Trip, Unknown Return Date
One Way Trip
Reason for One-way Trip
*
Medevac
Driving One-way
Personal
Other
Other
Appointment Dates & Travel Dates
Please provide the start date and time of your first appointment and the date and time you expect to finish your final appointment (including any recovery time).
Travel Dates
*
I know my specific travel dates
Book the best option for me based on my appointment
Appointment Date (or when you must arrive)
*
Your earliest appointment date and time. Include lab work or pre-procedures required.
Appointment Time
*
6:00 AM
7:00 AM
8:00 AM
9:00 AM
10:00 AM
11:00 AM
12:00 PM
1:00 PM
2:00 PM
3:00 PM
4:00 PM
5:00 PM
6:00 PM
7:00 PM
8:00 PM
9:00 PM
10:00 PM
Appointment End Date/Discharge Date
*
Please enter the date and time you think your last appointment will be completed, or when you are able to leave after recovery from a procedure, surgery etc. We will book the best available flight at least 3 hours after this time.
Appointment End Time/Discharge Time
*
6:00 AM
7:00 AM
8:00 AM
9:00 AM
10:00 AM
11:00 AM
12:00 PM
1:00 PM
2:00 PM
3:00 PM
4:00 PM
5:00 PM
6:00 PM
7:00 PM
8:00 PM
9:00 PM
10:00 PM
Your Preferred Departure Date
*
Your Preferred Departure Time
*
Morning
Afternoon
Evening
Anytime
Your Preferred Return Date
*
Your Preferred Return Time
*
Morning
Afternoon
Evening
Anytime
Air
Departure Airport
*
Aklavik
Calgary
Colville Lake
Deline
Edmonton
Fort Good Hope
Fort McPherson
Fort Simpson
Fort Smith
Gameti
Hay River
Inuvik
Lutsel k'e
Norman Wells
Paulatuk
Sachs Harbour
Toronto
Tulita
Ulukhaktok
Vancouver
Wekweeti
Whati
Whitehorse
Yellowknife
Destination Airport
*
Aklavik
Calgary
Colville Lake
Deline
Edmonton
Fort Good Hope
Fort McPherson
Fort Simpson
Fort Smith
Gameti
Hay River
Inuvik
Lutsel k'e
Norman Wells
Paulatuk
Sachs Harbour
Toronto
Tulita
Ulukhaktok
Vancouver
Wekweeti
Whati
Whitehorse
Yellowknife
Destination Airport Two
*
Aklavik
Calgary
Colville Lake
Deline
Edmonton
Fort Good Hope
Fort McPherson
Fort Simpson
Fort Smith
Gameti
Hay River
Inuvik
Lutsel k'e
Norman Wells
Paulatuk
Sachs Harbour
Toronto
Tulita
Ulukhaktok
Vancouver
Wekweeti
Whati
Whitehorse
Yellowknife
Flight Special Requests (including airline preferences, seat selection, escorts travelling separately etc.)
Second Appointment Location and Details
Taxi/Charters
Charter Type
*
Medical Bus
Medical Taxi (not for short rides to/from airport or appointment within the same community)
Helicopter
Air Charter (not commercial flights)
Other
Other
Home Community
*
Aklavik
Behchoko
Fort Liard
Fort McPherson
Fort Providence
Fort Resolution
Jean Marie River
Nahanni Butte
Tsiigehtchic
Tuktoyaktuk
Whati
Wrigley
Charter notes (include vendor preferences, travel times, etc.)
Hotels
Hotel
*
I know which hotel I want to stay at
Book me closest to my appointment
Book me closest to the airport
Check In Date
*
Check Out Date
*
Hotel Name
*
Hotel Address (Location/Street and City)
*
Appointment Address (Location/Street and City)
*
Check In Date 2
*
Check Out Date 2
*
Hotel 2 Name
*
Hotel 2 Address
*
Appointment 2 Address
*
Number of beds
*
1
2
Hotel Special Requests
Passenger 1
Patient/Escort
*
Patient
Escort
Escorts must be over the age of majority.
First Name
*
Please enter your name as displayed on your government issued photo ID.
Last Name
*
Please enter your name as displayed on your government issued photo ID.
Date of Birth
*
Gender
*
F
M
X
Please enter your gender as displayed on your government issued photo ID.
Phone Number (if different from employee)
Email (if different from employee)
Passenger Notes
Special Mobility Assistance (Meet and Assist)
Personal Wheelchair, Manual
Personal Wheelchair, Battery-Powered
Mobility Aid (Walker, Cane, or Crutches)
Portable Oxygen Concentrator
Requires Additional Seat
Unaccompanied Minor
Other
Other
Aurora Rewards Number
Aeroplan Rewards Number
WestJet Rewards Number
Passenger 2
Patient/Escort
*
Patient
Escort
Escorts must be over the age of majority.
First Name
*
Please enter your name as displayed on your government issued photo ID.
Last Name
*
Please enter your name as displayed on your government issued photo ID.
Date of Birth
*
Gender
*
F
M
X
Please enter your gender as displayed on your government issued photo ID.
Phone Number
Optional, if different from employee phone number
Email
Optional, if different from employee email
Passenger Notes
Special Mobility Assistance (Meet and Assist)
Personal Wheelchair, Manual
Personal Wheelchair, Battery-Powered
Mobility Aid (Walker, Cane, or Crutches)
Portable Oxygen Concentrator
Requires Additional Seat
Unaccompanied Minor
Other
Other
Aurora Rewards Number
Aeroplan Rewards Number
WestJet Rewards Number
Passenger 3
Patient/Escort
*
Patient
Escort
Escorts must be over the age of majority.
First Name
*
Please enter your name as displayed on your government issued photo ID.
Last Name
*
Please enter your name as displayed on your government issued photo ID.
Date of Birth
*
Gender
*
F
M
X
Please enter your name as displayed on your government issued photo ID.
Phone Number
Optional, if different from employee phone number
Email
Optional, if different from employee email
Passenger Notes
Special Mobility Assistance (Meet and Assist)
Personal Wheelchair, Manual
Personal Wheelchair, Battery-Powered
Mobility Aid (Walker, Cane, or Crutches)
Portable Oxygen Concentrator
Requires Additional Seat
Unaccompanied Minor
Other
Other
Aurora Rewards Number
Aeroplan Rewards Number
WestJet Rewards Number
Patient/Escort
Radio Buttons
*
Patient
Escort
Escorts must be over the age of majority.
First Name
*
Please enter your name as displayed on your government issued photo ID.
Last Name
*
Please enter your name as displayed on your government issued photo ID.
Date of Birth
*
Gender
*
F
M
X
Please enter your gender as displayed on your government issued photo ID.
Phone Number
Email
Optional, if different from employee phone number
Passenger Notes
Special Mobility Assistance (Meet and Assist)
Personal Wheelchair, Manual
Personal Wheelchair, Battery-Powered
Mobility Aid (Walker, Cane, or Crutches)
Portable Oxygen Concentrator
Requires Additional Seat
Unaccompanied Minor
Other
Other
Aurora Rewards Number
Aeroplan Rewards Number
WestJet Rewards Number
Passenger 5
Patient/Escort
*
Patient
Escort
Escorts must be over the age of majority.
First Name
*
Last Name
*
Date of Birth
*
Gender
*
F
M
X
Phone Number
Email
Passenger Notes
Special Mobility Assistance (Meet and Assist)
Personal Wheelchair, Manual
Personal Wheelchair, Battery-Powered
Mobility Aid (Walker, Cane, or Crutches)
Portable Oxygen Concentrator
Requires Additional Seat
Unaccompanied Minor
Other
Other
Aurora Rewards Number
Aeroplan Rewards Number
WestJet Rewards Number
Patient/Escort
Radio Buttons
*
Patient
Escort
Escorts must be over the age of majority.
First Name
*
Last Name
*
Date of Birth
*
Gender
*
F
M
X
Phone Number
Email
Passenger Notes
Special Mobility Assistance (Meet and Assist)
Personal Wheelchair, Manual
Personal Wheelchair, Battery-Powered
Mobility Aid (Walker, Cane, or Crutches)
Portable Oxygen Concentrator
Requires Additional Seat
Unaccompanied Minor
Other
Other
Aurora Rewards Number
Aeroplan Rewards Number
WestJet Rewards Number
Submit
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