Application for Admission

(International/Permanent Resident)

Please fill out the entire form before you submit the form. If you have questions about any part of the form please call (316) 322-3230.

Personal Information
Name (Last, First, Middle)
Phone Number
Home Country Address
P.O. Box
State or County
Country you now reside in
E-mail Address
Local Phone
Local US. Mailing Address (if available)
State or Country
    Local Phone

Demographic Information
Date of Birth (mm,dd,year)
Social Security or Butler I.D., if applicable
I agree to share academic and directory information to outside agencies or institutions such as Armed Forces, employment agencies, colleges and universities, etc. This information will be used for research purposes, military recruiting and verification purposed only.
Yes No *
Marital Status

Educational Goal Information
Are you the first person in your immediate family to attend college?
When are you planning to enroll? Semester
Have you previously attended Butler?
If yes, date last attended
If you are seeking a degree with Butler, please indicate which one
If you are seeking a certificate with Butler, please indicate which one
Please select which statement best describes your objectives with Butler?

Residency Status
Are you an immigrant permanent resident? Yes No (If yes, complete the permanent resident information section)
Are you a Kansas Resident? Yes * No * If yes, date residency began
Are you an international student? Yes No (If yes, complete the international information section)

High School Information
When and where did you graduate from high school or receive your GED, or where are you currently attending high school? Month Year
High School/GED Center * City Country
Previous College Information
In area provided list any colleges, universities, or vocational-technical schools you may have attended. (Please include institution name, city, state, country, dates attended, hrs earned and what degree or certificate was earned if any)

Emergency Information
Home Country Emergency Contact Person
Name Relationship
Street City Country Zip
Home Phone Work Phone
Local (USA) Emergency Contact Person
Name Relationship
Street City State Zip
Home Phone Work Phone

International & Permanent Resident Information
International Information: Guest students provide a letter of permission from the school noted on their I-20. All other students must provide documentation of English proficiency, financial support and transcripts.
Please indicate the type of Visa you are currently on or requesting F-1(Student)
Country of Birth * Country of Citizenship *
Permanent Resident Information: Permanent residents must provide a copy (front and back) of their "green card" or other documentation demonstrating eligibility for permanent residency.
Resident Alien Card A# Date Issued Date expired
Country of Birth Country of Citizenship

Other Background Information  
Other names your records may be found under
Current place of employment
Are you a single parent? Yes No
Father's education level
Mother's education level
Are you on active military duty in the USA? Yes No
       If yes, do you plan to use military tuition assistance? Yes No

Anyone needing information concerning Disability Services should contact the Disability Services Office at (316) 322-3166 or (316) 733-3166

CERTIFICATION College policy requires an official transcript be sent from each institution you have attended. It is your responsibility to make sure that each transcript is sent to BCCC. If all transfer hours are not on file in the Registrar's Office, you will not be able to enroll for the next semester and a hold will be placed on your records. By pressing the submit button you are certifying that all the information is complete and correct. Any changes of address or name must be filed with the Registrar's Office immediately.  


NOTICE OF NONDISCRIMINATION Applicants for admission and employment, students, parents, employees, sources of refernal of applicants for admission and employment and all usons or professional organizations holding negotiated agreements or professional agreements with the institiution are hereby notified that this institution does not discriminate on the basis of race, religion, color, national origin, sex age or disability in admission or access to, or treatment of emplyment in its programs and activites. Any person having inquiries concernning Butler County Community College's compliance with the regulations implementing Titla VI, Titla IX and Americans with Disability Act of 1990 is directed to contact the coordinators who have been designated to coordinate the educational institution's efforts to compy with the regulation implementing these laws.
Specific complaints of alleged discrimination under Title IX (sex) and Section 504 (handicap) should be referred to:

Kent Williams-VP, Finance
901 South Haverhill Road
El Dorado, KS 67042
(316) 322-3103 (Local)
(316) 733-3103 (Wichita Metro)

Disability Services Director
901 South Haverhill Road
El Dorado, KS 67042
(316) 322 3321 (Local)
(316) 733-3321 (wichita Metro)