Rev: 05/16
Office of the Registrar
Enrollment Verification Letter Request
Name: _____________________________________ Liberty Student ID: __________________
Previous Name: ______________________________ Date of Birth (mm/dd/yy):____/____/____
Email: _____________________________________ Phone Number: (_____) _____-________
Delivery Options: Special Instructions & Purpose:
Pickup Attach form included with request
Send to the below address: Other:_______________________
Attn:______________________________ ____________________________
Address:___________________________ Purpose:
__________________________________ Insurance Deferment
__________________________________ DMV Other:_________
Fax: __________________________________ Verification of:
Email: ________________________________ Enrollment Status (Full Time/Part Time)
Quantity Requested:________________________ Degree Conferral
Semester: Fall Spring Summer Standing
Student’s Signature:_________________________________________ Date:_____________
*By signing this form you authorize the LUCOM Registrar’s Office to send your enrollment verification(s) to the designated person or
organization listed above.
Submit Request(s) to:
College of Osteopathic Medicine
Registrar’s Office
306 Liberty View Lane, Lynchburg, VA 24502
Tel. (434) 592-5200 · Fax (434)582-3902 ·
*Allow 3-5 business days for processing.
Student Information (Please Print)
Request Information (Please Print)
Authorization (Please Print & Sign)
Contact Information & Instructions
Registrar’s Use Only Processed By:______________________ Date:_______________
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