Bucks County Community College
Withdrawal Form

This form is NOT submittable on-line. You must fill it out, print it, and mail it to:
 Bucks County Community College, Office of Admissions, Records and Registration
275 Swamp Road, Newtown PA, 18940
This form MUST be received by the semester withdrawal deadline.

Student Number
              

_________________________________
Last Name................First .................M.I.

Home Phone _______________________

Work Phone _______________________

Social Security No. _________________

Check here if you are veteran

Check here if receiving Financial Aid

Student Signature_________________________Date_________

  
_____
YEAR		       Fall
Intersession
Spring
Summer I - 6 week
Summer I - 8 week
Summer II

Circle letter(s) of reason(s) for this withdrawal:
A. Personal ProblemsF. Personal/family illness
B. Trans. DifficultyG. Tired of study/classes
C. Family oppositionH. Disliked course(s)
D. Disliked instructionJ. Job situation changed
E. Academically unpreparedK. OTHER: (explain)

Request permission to WITHDRAW from:

Course Number    Section       Course Title       Credits
    
    
    
    
    
    
Total credits withdrawn 
Total term credits after withdrawal 

 
FOR COLLEGE USE ONLY

Received by: ___________ Date: ___________ Processed by: ___________ Date: ___________