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. *Address:
5. *City: 6. *State:
7. *Zip: 8.*Home Phone:
9. *VA File Number: (Veteran's SSN if using Chapter 35)
10. *E-Mail Address:
11. *Status: 12. *
13. Please select if any of the following apply to you: Active Duty: Tution Assistance: or Financial Aid:

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

VA Counselor's Address (City, State):

14. *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.

15. *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:

16. *List the Courses you are taking this semester.
(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)

Office Use Only:

Academic Advisor:
(signature provides approval of course selection)

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

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