Date of Birth
Enter at least one phone number:
Do you currently serve in the National Disaster Medical System?
Do you possess a valid driver's license?
Are you at least 18 years old?
Are you a U.S. citizen?
Enter at least one phone number for your emergency contact:
Has your professional license or certification ever been suspended or revoke in New Jersey or any other state?
Do you have any of the following skills?
Have you completed any training or continuing education programs in the following areas?
As a volunteer with the New Jersey Medical Reserve Corps, I will be called upon to assist in the event of a public health emergency. I agree to attend an education program to explain my role in disaster preparedness; I will be assigned duties based on my level of training and experience. I understand that submitting this application does not guarantee acceptance into the NJ Medical Reserve Corps. The information contained in this application is, to my knowledge, truthful. I agree to serve my fellow citizens to the best of my professional ability.
I agree to the above statement. Failure to agree to the above statement invalidates application.