Joining the Team‎ > ‎

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


10 Wistars Mill Lane

Woodstown, NJ  08098

Fax: 856-769-0556