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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

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