Policy Variance Request

First Name

Last Name

Registry Number or EMS ID (if applicable)

Application ID or Candidate ID (if applicable)

Pearson VUE case number (if applicable)

Primary email address

Phone number

Address

Address 2 (optional)

City

State

Zip Code

Category of Request

Reason for Request

Attachment: Upload your supporting documentation.

Please select a file

Examples of supporting documentation include but are not limited to: military orders or memo from commanding officer, medical provider's note that includes dates of illness/injury, obituary , supervisor's note on letterhead with signature , weather report or county declaration of a weather emergency during the time of your scheduled examination or request. Please, do not send personal medical records. An attachment is required for the consideration of additional time or certification eligibility or no-show examination status.

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I attest that all information is true and accurate to my knowledge.

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Your request will be reviewed once this form is completed, submitted, and received by National Registry. This includes providing an attachment to support your request, when applicable. Submission of this request is for consideration and review and is not a guarantee that a variance will be approved or granted. Some requests may require additional validation from a State EMS Office or Designated Authorizing Agency. We process requests in order received.