Rev: 10/17
MSPE Request Form
Name: __________________________________________ Liberty Student ID: __________________
Previous Name: __________________________________ Date of Birth (mm/dd/yy):____/____/____
Email: ___________________________________________ Phone Number: (_____) _____-________
Current Student Options:
Upload to:
____________________________
Other:
____________________________
____________________________
____________________________
Alumni Options:
Mail to below address
Attn:________________________
Address:_____________________
____________________________
____________________________
____________________________
Student’s Signature:_________________________________________ Date:_____________
*In compliance with FERPA, by signing this form you give your written consent and authorize the LUCOM Registrar’s Office to release your
MSPE to the designated person or organization listed above, and you agree to the applicable charges.
Submit Request(s) to: College of Osteopathic Medicine, Registrar’s Office, 306 Liberty View
Lane, Lynchburg, VA 24502 · Fax (434)582-3902 · lucomregistrar@liberty.edu
If applicable, include a check or money order payable to “Liberty University.” If FedEx
Overnight* delivery is requested, a shipping charge of $20 should be added to order. *FedEx will
not accept Post Office Box and APO addresses. *$20 shipping charge only applies to US &
Canada addresses. If an international delivery is necessary, please contact the LUCOM Registrar’s
Office.
Cost: First 10 requested LUCOM MSPEs are free and $5 per copy afterwards. Payment with
credit/debit card is accepted. Please call (434) 592-5200 to use this payment method. Sending an
MSPE to more than one location counts as more than one request.
The Medical Student Performance Evaluation (MSPE) is a formal letter of objective evaluation
summarizing the levels of accomplishment a student has achieved during medical school. The
MSPE provides a succinct chronology of the student’s entry and progress through medical
school, including preclinical and clinical rotation records (including preceptor comments),
noteworthy characteristics, commentary on the student’s professional performance while in
medical school, and the student’s class rank (if applicable).
Students may be permitted to review their MSPE prior to it being uploaded or sent. Students can
only view their MSPE in the Office of the Registrar. To schedule a review, please contact the
Office of the Registrar via email.
Allow 3-5 business days for processing.
Registrar’s Use Only Processed By:______________________ Date:_______________
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