Sussex County Medical Reserve Corp

Sussex County Medical Reserve Corps

Sussex County Division of Health

One Spring Street/2nd Floor

Newton, NJ 07860

973-579-9488

Fax: 973-579-9773

Medical Volunteer Application Form

Please print or type:

Last Name First Name Middle Initial

Mailing Address City State Zip

Telephone Email Fax Pager

Degree (s) Certifications:

Medical Specialty

Year of Retirement or Current License #

** Please Note: All applicants will be background checked before registration with the MRC **

Date of Birth Social Security Number

Signature Date

Are you available to participate in a Public Health Training Exercise April 7, 2005?

Yes No___

Please complete this application and send Email: ; Fax: 973-579-9773

Or Mail to: Sussex County Division of Health

Medical Reserve Corps

One Spring Street/2nd Floor

Newton, NJ 07860

Thank you for your willingness to consider participation in this essential service. If you should have any questions about this application, or the volunteer request in general, please call 973-579-9488.