Fillable 1819 LUCOM Tobacco Region Discount Form

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1819 LUCOM Tobacco Region Discount Form

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LU ID # ____________________________
Student Name _______________________
Liberty University College of Osteopathic Medicine
1971 University Boulevard • Lynchburg, VA 24515 • Phone: (434) 592-6700
Web Site: http://www.liberty.edu/lucom • E-mail: LUCOMFinancialAid@liberty.edu
TCOF
18/19
LUCOM Tobacco Region Discount Request Form
Award: LUCOM students who were officially domiciled residents in one of the designated Virginia Tobacco
Commission areas for at least three years preceding acceptance into the COM or who graduated from high
school or college within the Tobacco Commission area are eligible for a 5% renewable tuition discount.
Eligibility:
• Must be in good standing academically and professionally.
• Must consent to image, story, and information release for press for a period of 20 years after graduation.
• Must maintain Financial Aid Satisfactory Academic Progress.
Additional Requirements:
• Must provide documented proof of domiciled residence or graduation from high school or college within the
Tobacco Commission area (Example: transcripts, pay stubs, W2s, billing address showing three years of
residency, voter registration, etc.).
Certification (Choose all that apply):
I am sending documentation of three or more years of domiciled residence in the Virginia Tobacco
Commission area prior to acceptance at LUCOM.
I am sending documentation of my graduation from a high school within the Virginia Tobacco
Commission area.
I am sending documentation of my graduation from a college or university within the Virginia Tobacco
Commission area.
Comments:
By completing this from, I certify that all the information reported is complete and correct. By signing this worksheet, I certify that all
the information reported on it is complete and correct. Because this information may affect federal aid eligibility, purposely giving
false or misleading information may cause you to be fined up to $20,000.00, sent to prison or both.
__________________________________________________ ________________________
Student Signature Date
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1819 LUCOM Tobacco Region Discount Form

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Completed 25 January 2020

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