Submit completed form to PSI:
• Mail: PSI, 18000 W. 105th St., Olathe, KS 66061-7543• Fax: 913-895-4650
Request for (check one):q Substitution

q Cancellationq Rescheduling•	To make a substitution, you must submit a completed Substitution/Cancellation Form accompanied by acompleted DAANCE Registration Form (page 19) and a valid CPR, BLS or ACLS card for the new registrant.
•	Substitutions must be made a minimum of 30 days before the candidate’s expiration of eligibility.*
Note: A candidate may be permitted to participate in only one substitution per eligible record.
• Cancellations will not be accepted after 90 days of candidate’s activation.
•	If a cancellation is made before 90 days, the sponsoring doctor will receive a refund equal to 50 percentof the registration fee.
•	Rescheduled appointment dates must be before the candidate’s expiration of eligibility. Note that
rescheduling does not extend eligibility.* An $95 rescheduling fee may apply.
•	New course material will not be provided to the substitute registrant.
REQUEST FOR SUBSTITUTION/CANCELLATION OR RESCHEDULING
Name _______________________________________________________________________________________
Candidate/DAANCE ID _________________________________________________________________________
Registrant (Substitute) to be enrolled:
Name _______________________________________________________________________________________
Candidate/DAANCE ID _________________________________________________________________________
Sponsoring Doctor
Sponsoring Doctor Name _______________________________________________________________________
Address _____________________________________________________________________________________
City __________________________________________________ State ___________ ZIP __________________
Phone ________________________________________________ Fax __________________________________
Email _______________________________________________________________________________________
Signature of person requesting substitution or cancellation______________________________________________________________________ Date _________________
Please note: You will receive written confirmation regarding your request within 10 business days.
If you do not receive written confirmation within that time period, please contact PSI at 833-333-4755.
REQUEST TO RESCHEDULE TEST APPOINTMENT
Candidates may reschedule ONE appointment within the eligibility period at no charge; a rescheduling feeof $95 is required for any subsequent appointment change within the eligibility period. PLEASE NOTE: If thisis your first request to reschedule your test appointment, you do not need to complete this form, but PSI must
be contacted at least two business days in advance of your appointment date.
It is your responsibility to complete and submit this form according to the AAOMS Candidate
Handbook Policies.
detach here "Payment type:24

q Check for $95 payable to PSI Services, Inc. enclosed

q Credit Card (MasterCard or Visa)

Credit Card #_______________________________________ Security Code __________ Expiration Date __________Name of Cardholder: __________________________________________________________________________*Failure to comply will result in a candidate’s registration being forfeited.

DAANCE Substitution/Cancellation Form

DAANCE Substitution/Cancellation/Reschedule Form