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