EMS Interstate Compact (REPLICA) Application

Date of Application:*
MM slash DD slash YYYY
Agency Applying for EMS Interstate Compact (REPLICA) Staffing:*
Agency OEMS License #:
Agency Administrative Contact:*
First Name Last Name
Phone:*
Email:*
Requesting to utilize EMS Interstate Compact (REPLICA) providers from:*
Month
Day
Year
to*
Month
Day
Year
Please note: If a provider is needed for more than 30 days, the applicant will have to apply for reciprocity through the Accreditation, Certification and Education (ACE) Division with the Virginia Office of EMS and receive a Virginia EMS certification.
All fields must be completed for each EMS Interstate Compact (REPLICA) provider to be hosted.
*
First Name Last Name Home State License # License Level License Expiration Date Contact Number *National EMS I.D. #
* Your National EMS I.D. number is the 12-digit numerical number found on your National Registry account. It is NOT your National Registry number.

First Name	Last Name	Home State	License #	License Level	License Expiration Date	Contact Number	*National EMS I.D. #

All fields must be completed for each EMS Interstate Compact (REPLICA) provider to be hosted.