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Temporary Vehicle Use Application

An EMS agency may operate a temporary replacement EMS vehicle without securing prior approval from the Department. It shall submit a temporary replacement vehicle form to the regional EMS council through which its license application was processed, by completing the form below before putting the EMS vehicle in service. In the form, the EMS agency shall attest to the fact that the EMS vehicle satisfies the requirements for that type of EMS vehicle that are imposed by regulation and notices published in the Pennsylvania Bulletin. Upon submitting a temporary replacement vehicle form, the EMS agency may continue to operate the temporary replacement EMS vehicle unless its authority to do so is disapproved by the inspector following an inspection of the EMS vehicle.

Upon receiving a temporary replacement vehicle form, the regional EMS council shall issue a temporary certificate which authorizes the EMS agency to operate the temporary replacement EMS vehicle for seven (7) days based upon its attestation that the vehicle satisfies all requirements.

A temporary vehicle not currently licensed with an EMS agency that is to be utilized for more than seven (7) days must be inspected by the regional EMS council. Upon successful inspection, a new temporary certificate will be issued.

A temporary vehicle is a vehicle NOT owned by the EMS agency that is utilizing it.

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 #

Complete the Following for the Temporary Vehicle

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 *

Please list the date ranges for the anticipated use of the temporary vehicle.

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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