Medical Reserve Corps

If you would like to apply to become an MRC volunteer please complete the form below online or click here to print the PDF of the volunteer application. You can return your printed application via mail or fax.

First Name
Middle Name
Last Name
Address
City
State
Zip code
Home email
Work email
Home phone
Work phone
Cell phone

In which of the following areas would you be willing to volunteer?

Virginia
   City of Suffolk
   Franklin
   Southampton County
   Isle of Wight County

North Carolina
   Hertford County
   Gates County

Who is your current employer?
What is your job title?
Employment status    Fulltime   Part-time   Retired

Please mark the following positions that you have the skills and certifications to perform:

   Physician    Specialty
   Physician Assistant
   Nurse Practitioner
   RN
   LPN
   EMT/Paramedic
   Nurses Aide
   Pharmacist
   Veterinarian, Vet Tech, or Assistant
   Mortuary Professional
   Mental Health Professional
   Administrative Support
   Site Coordination
   Health Education
   Communications
   Other

What medical license do you have? With what state   VA    NC
When does your license expire?

List any additional licenses, professional training, or certifications that you have acquired:

Additional Information:

Volunteers will be subject to a license and background check.

Download Printable Application (PDF)