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Request for Duplicate Certicate and/or Pin Form

Request for Duplicate Certicate and/or Pin Form

To order a replacement certicate: Please complete this form and send it to the address listed below

with a $20 check payable to AAOMS.

Note: If you need a certicate from the current year,

please call PSI at 833-333-4755 for a replacement copy.

To order a replacement pin: Please complete this form and send it to the address listed below with

a $10 check payable to AAOMS.

Your name at the time you took your exam (if dierent)

Sponsoring doctor’s name at the time you took your exam

Year and month you took the exam (if you don’t remember, please write the approximate year)

Mailing address (please indicate if this is your home or work address)

Contact phone number or email address

The information on this form is condential and may be legally privileged. It is intended solely for the addressee.

If you are not the intended recipient, any disclosure, copying, distribution or any action taken or omitted to be

taken in reliance on it is prohibited and may be unlawful.

detach here "