(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 |
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