Bucks County
Community College
275 Swamp Road
Newtown, PA 18940-4106
(215)
968
-8100 Phone
(215) 968-8110 FAX
Please fill out form and do one of the following
things:
1. Print, sign, and either mail or fax to us at
215-968-8110
2. After completing the form, save to your
computer and email to
Carol.Ladd@bucks.edu using your Bucks
email account. (Submissions from
personal email accounts will not be
accepted.)
CONSENT FORM
Please allow a minimum 7-10 business days for processing
I, ______________________________ give Bucks County Community College authorization to complete
(print name)
and sign the transfer evaluation form including disciplinary and academic records for the following school(s):
_____________________________ ____________________________________________________________
(school name) (office/attention and street address)
____________________________________________________________
(city, state zip)
____________________________________________________________
(fax number/email)
_____________________________ ____________________________________________________________
(school name) (office/attention and street address)
____________________________________________________________
(city, state zip)
____________________________________________________________
(fax number/email)
_____________________________ ____________________________________________________________
(school name) (office/attention and street address)
____________________________________________________________
(city, state zip)
____________________________________________________________
(fax number/email)
**If you are sending reports to more than three institutions, please continue on another form
Student signature: ___________________________________ Student ID number: __________________
Bucks email address: ____________________________________________________________
Student phone number: ______________________________
Date: _____________
__________________________________________________________________________________________
To Be Completed by Bucks County Community College Departments
Dates Enrolled: ______________ GPA: ______________ Disciplinary Action: ______________
Mailed/Emailed/Faxed:______________
