Temporary Vehicle Replacement Form

Name of EMS Agency *

Street Address *

City *

State/Region Abbreviation

Affiliate Number

Complete the Following section for Vehicle that is currently Out of Service

Out of Service Year

Out of Service Model

Out of Service Make

Out of Service VIN or Aircraft #

Out of Service License Plate or FAA #

Vehicle Model *

Temp. Vehicle Year *

Temp. Vehicle Make *

Temporary License Plate or FAA # *

PA DOT Inspection Expiration Date *

Temp VIN or Aircraft Serial Number *

Name on DOT Vehicle Registration Card *

Starting Date *

End Date *

I agree to operate the temporary vehicle under the conditions contained in the Pennsylvania EMS Rules and Regulations

First Name *

Email *

Job Title

Last Name *

Phone *

Signature Date

We have received your temporary vehicle replacement. We will be in touch within 24-48 hours.

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