Please complete the form to receive your credits from USC/LLR. Failure to do so will prevent you from receiving them. Name on License * First Name Last Name LLR Number * Type of License * Cosmetology Nail tech Esthetician Email * Address Address 1 Address 2 City State/Province Zip/Postal Code Country Phone * (###) ### #### LAST 4 of SSN * Date Attended * MM DD YYYY Thank you!