Intersession Registration Form

Over-the-Counter Intersession Registration (with payment) will be accepted in the Admissions Office
until December 21: Mon.-Fri., 7:45am-4pm and/or in the Evening Office: Mon.-Thurs., 5-8pm

INSTRUCTIONS: Please fill this form out completely, then print out, sign, and mail to the address below.
This form may NOT be submitted electronically.

HEW Report

American Indian or Alaskan Native

Asian or Pacific Islander

Black Non-Hispanic Origin

White Non-Hispanic Origin

Hispanic

High School Attended

State Graduation Date

Have you ever attended a college/university?
YES NO

If YES, which one?

Employer's Name

Address

	YES	NO
Are you a legal resident of Bucks County?
Are you a legal resident of Pennsylvania?
Are you a citizen of the U.S.?
Have you ever made application to Bucks before?
Have you ever enrolled at Bucks before?
If YES, give dates from to
Do you intend to earn an Associate degree from Bucks?
Have you ever attended Bucks under another name?
If YES, what name?

Signature _________________________________ Date _____________________

By my signature, I recognize my responsibility to read, understand and abide by the rules and procedures printed in the College Catalog and this brochure. I will further recognize that I will not be exempted from the requirements of these rules and procedures because of ignorance, negligence, illnesses, other personal factors or contradictory advice from any source.

SESSION	COURSE NO.	SECTION	COURSE TITLE	BILLABLE CREDITS

NOTE: To indicate your intention to "Audit" a course, write "AU" after the section number			TOTAL CREDITS

FILL OUT AND MAIL ENTIRE FORM

STUDENT NUMBER	SOCIAL SECURITY NUMBER
	· ·

Complete this registration form (and if neccessary, the Veteran's Benefits Form) and mail with your check, money order or Credit Card information filled out below to:

Office of Admissions, Records & Registration
Bucks County Community College, 275 Swamp Road, Newtown, PA 18940

All previous balances due by students to Bucks County Community College must be paid prior to registration for this semester.

Name

Address

City St. Zip

FOR COLLEGE USE ONLY

AMT.REC'D

REC'D BY

DATE

TUITION AND FEES

DO NOT SEND CASH

	In-county (3 credits)	Out-of-county (3 credits)	Out-of-state (3 credits)
New Student	$394.00	$703.00	$1,012.00
Return Student	$364.00	$673.00	$982.00

TOTAL AMOUNT DUE

Signature _______________________	*Cardholder's Name
Card Number	Cardholder's Signature _______________________
Visa Master Card Discover	Expiration Date

*Cardholder must be self, spouse or parent.

FOR COLLEGE USE ONLY

ADMIT FTE CURR RES
APPLIC ETS DEG GRAD

Name
Address
City	State Zip
Telephone	(H) (W)
Birthdate	Sex Female Male
Major Name (from list)	Code Number