Transferring Student Admission Report

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Student: Please print this form. Complete Part I and submit the form to the Dean of Students at the school you are presently attending or the last school attended for completion of Part II.
Part I. To be completed by Transfer Applicant. (Please type or print.)

Name ___________________________________________________________

Address _________________________________________________________

City, State, Zip ____________________________________________________

College (Attending or Attended) ______________________________________

_________________________________________________________________

Dates of Attendance _______________________________________________

I authorize the release of the information below to the Office of Admission at Lycoming College.

_____________________________ ___________________ ____________________
SIGNATURE OF APPLICANT SOC. SEC. # DATE

Part II. To the Dean of Students: This student is applying to Lycoming College as a transfer student. We appreciate your cooperation in providing us with the following information.

A. Is this student eligible to continue at your institution? If 2 or 3, please explain.

1. Yes ______ 2. Yes, conditionally ______ 3. No ______

B. Has the student been the subject of formal disciplinary action? If yes, please explain.

1. No ______ 2. Yes ______

C. Does the student have any physical, mental, or emotional problems which should be brought to our attention? If yes, please explain on an attached sheet.

1. No ______ 2. Yes ______

D. Are there any special circumstances in the student’s background that should be considered? If yes, please explain on an attached sheet.

1. No ______ 2. Yes ______

E. The above information is based upon:

Records and reports only ______ Casual contact ______

Personal acquaintance ______ Counseling contact _______

_________________________ ____________________ _____________________
Your Name Title Institution

Thank you. All applicant information is considered confidential and treated accordingly. Please return this completed form to: Dean of Admission, Lycoming College, Williamsport, PA 17701-5192.

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