Step 3 - Member Information Form

NJ-1 DMAT Prospective New Member Information Form

(Please Print, Complete and Return with Resume and Credentials)

Date: ______________________________

New Member ______ Transfer Member ______

Current DMAT/NDMS Affiliation: (if applicable) _______________________________

Current DMAT Position: (if applicable) _______________________________

Name: ____________________________________________________________

Address: ____________________________________________________________

____________________________________________________________

Home Phone No.: _________________________________________

Work Phone No.: _________________________________________

Cell Phone No.: _________________________________________

Pager No.: _________________________________________

Fax No.: _________________________________________

E-mail Address: _________________________________________

Position Applying For

__ Nurse Practitioner

__ Physician

__ Physician Assistant

You must submit a detailed resume, which shows a minimum of one-year full-time (equivalence if part-time) experience performing the job position for which you are applying. A copy of ALL appropriate credentials must accompany your resume. Please return all materials to:

Catherine Morrison

Administrative Officer

NJ-1 DMAT

10 Wistars Mill Lane

Woodstown, NJ 08098

Fax: 856-769-0556