REQUEST FOR CREDIT BY
LICENSURE / CERTIFICATION
LFCC Office of the Registrar · 173 Skirmisher Ln · Middletown, VA 22645
Telephone: 540-868-7105 Email: records@lfcc.edu Fax: 540-868-7005
For office use only
Electronic signature verified by: _________________ Processed by: _____________ Date __________________
LFCC Office of the Registrar Use Only Revised 4/10/2020
Student ID: Date of Birth:
Student Name:
Last First Former
Address:
City: State: Zip Code:
My Planned Program(s) of Study:
Student Signature: Email: @email.vccs.edu
I voluntarily consent to the use of an electronic record of my LFCC student file. I acknowledge that, by logging into the MYLFCC system with my unique credentials and e-
mailing from my @email.vccs.edu account to provide LFCC with this data, I have given my electronic signature which has the same legal and binding effect as a "wet" or
handwritten signature.
Student must attach a copy of the official credential for evaluation. If the submitted credential is not in the Credit for Prior Learning
Guide, faculty or dean will evaluate for possible transfer credit. When official copies have been received credential(s) will be
evaluated and student will be notified via their VCCS email account.
Please check one:
☐ This credential is pre-approved credit as listed in LFCC’s Credit for Prior Learning Guide.
☐ This credential has not been pre-approved for transfer credit and I request that it be evaluated by faculty and/or the dean.
Faculty Signature / Date ☐ Documentation attached
If Division Dean approval is needed: ☐ Approved ☐ Not Approved
Dean Signature / Date
Notes:
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