A-516 Isolation Reservation Request Form

Isolation Reservation Request Form

Every adult (18 years of age or older) must complete an Isolation Reservation Request Form.
Adults and families traveling in the same group who plan to isolate together must submit their forms in one email submission. Travellers who enter isolation with pets bear full responsibility for the animal's welfare and all applicable costs and fees associated with their pet.

Date of Request

Resident of Nunavut

Yes

Isolation Applicant Information

One form must be competed per adult (18 years of age of older)

First

Middle

Last

Date of Birth

Name of Employer

Position Title

Personal Email Address

Employee Primary Conact Number(s)

Return Destination Community (within Nunavut)

Mailing Address (Apt., house#, street, P.O.)

City/Town

State/Province

ZIP/Postal Code

Dietary Restrictions

I am travelling with other adult(s)

If yes, please provide the name of other adult(s) you are requesting to isolate with:

Enter other…

List all dependent children travelling in your group (name & date of birth)

Nunavut Travel Information

Airline reservations must be confirmed; i.e., standby or buddy pass tickets are NOT ACCEPTED

Airline Reservation Code

For Return Ticket to Nunavut

Departure Date from Nunavut

Return Date to Nunavut

Southern point of entry into Nunavut

Ottawa

Winnipeg

Edmonton

Yellowknife

(This is the city you are required to isolate in. Return travel must be directly from point of isolation to Nunavut)

Please provide any additional information you feel is required for your isolation reservation to be processed:

Declaration

Please read carefully. By signing this application, I declare the information in this application and in any attachment, is true and accurate. I understand that if I choose to complete and submit this application electronically it will be equivalent to an electronic signature and will be treated in the same manner as if I had signed and submitted it through other means. Providing misleading or false information in response to these questions or to the office of the Chief Public Health Officer constitutes a breach of the Travel Restriction Order and can be punishable by a $575 fine.

Signature of Applicant

Sign above

Date

Submit completed form(s) to: @email

An isolation reservation confirmation letter will be emailed to the address provided within 3 business days.

Office of the Chief Public Health Officer
Department of Health
P.O. Box 1000, Iqaluit, NU X0A 0H0
www.gov.nu.ca/health

Steps

Current Isolation Reservation Request Form
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