Rev: 10/17
Transcript Request Form
Name: __________________________________________ Liberty Student ID: __________________
Previous Name: __________________________________ Date of Birth (mm/dd/yy):____/____/____
Email: ___________________________________________ Phone Number: (_____) _____-________
Delivery Options:
Upload to: _________________________
Mail to below address
Special Instructions:
Hold for degree
Other: ____________________________
Quantity Requested:_____________
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
transcript 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 ·
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
Cost: First 10 requested LUCOM transcripts are free and $5 per copy afterwards. Payment with
credit/debit card is accepted. Please call (434) 592-5200 to use this payment method.
Content: All information present in your ASIST account at the time of fulfillment will be
reflected on your transcript. Please note that the ASIST GPA is incorrect and not present on your
transcript. All medical level coursework will be included on your transcript. Undergraduate and
graduate level coursework at Liberty University, if any, will not be included.
No additional or unofficial copies of the student’s transcript will be issued to the student. If there
are changes to your transcript after the initial release, and you wish to have those changes
reflected, you must submit a new transcript request form.
Allow 3-5 business days for processing.
Student Information
Request Information
Registrar’s Use Only Processed By:______________________ Date:_______________
Additional Information
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