Barton Community College
Enrollment Certification Request

Great Bend Campus (800) 722-6842
Fort Riley Campus (785) 784-6606 or (877) 620-6606

* required fields
1. *First Name: *Last Name:
2.* Previous or Maiden Name: 3.*Soc.Sec. Number:
4.*Barton Student ID: 5. *Address:
6. *City: 7. *State:
8. *Zip: 9.*Phone:
10. *VA File Number: (Veteran's SSN if using Chapter 35)
11. *E-Mail Address:
12. *Status: 13. *
14. Please select if any of the following apply to you: Active Duty: Tuition Assistance: or Financial Aid:

Chapter 31 (Voc-Rehab) Only - VA Counselor's Name:

VA Counselor's Address (City, State):

15. *Declared Major at Barton Community College:

If you are NOT pursuing a degree at Barton Community College, name your *Primary School where you are currently earning your degree:
(School, City, State)
You will be required to provide a *Parent School letter from the school listed above.

16. *Indicate the Semester in which you are enrolling and the number of hours you plan to take:
(Choose ONE semester only - fill out a seperate online form for each semester)
Fall: Spring: Summer: Spring Intersession: Winter Intersession:

17. *List the Courses you are taking this semester. (Please note that MATH 1809, MATH 1821, ENGL 1194, and READ 1109 cannot be certified as online courses.
(list only Courses that apply toward the Degree program you listed in item 12.)

Course Reference Number Course Title & Code Type of Course
Please submit all official college transcripts to the campus in which you are VA certified.
(transcripts must be mailed directly from each school - no handcarried copies)

To help keep spammers from using our forms you will have to type Barton below before submitting

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