EMS Interstate Compact (REPLICA) Application

EMS Interstate Compact (REPLICA) Agency Application

  • MM slash DD slash YYYY
  • 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 NameLast NameHome StateLicense #License LevelLicense Expiration DateContact 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.