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
Note: Your name must match your legal name on your passport.
* = required
Last (Family) Name * First (Given) Name * Middle Name
E-mail Address
Phone Number *
Home Country Address
Street 1 *
Street 2
City *
State or County
Postal/Zip Code*
Country *
Country you now reside in
Home Country Phone Number
Local US. Mailing Address (if available)
State or Country
    US Local Phone Number

Demographic Information
Date of Birth (mm,dd,year)
Are you a U.S. citizen?*
If yes, STOP and complete the application for domestic students at
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
Are you Hispanic/Latino?
Yes     No

Educational Goal Information
Are you the first person in your immediate family to attend college?
What semester are you applying for?*
Have you previously attended Butler?
If yes, date last attended
What degree/certificate are you applying for?

Residency Status
Are you an immigrant permanent resident ("green card") or an applicant for permanent residency? * 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 will/did you graduate from secondary/high school? Month * Year *
Name of Secondary/High School * City * Country *
Previous College Information
List any colleges, universities, or vocational-technical schools you have attended. Include institution name, location, dates attended, and degree/certificate earned, including any English language programs.

Emergency Information
Home Country Emergency Contact Person
Name Relationship
Street Address Line 1 City Country Postal/Zip Code
Phone Number  
Local (USA) Emergency Contact Person
Name Relationship
Street Address Line 1 City State Zip
Phone Number  

International & Permanent Resident Information
Country of Birth * Country of Citizenship *
Do you currently have a visa?* If yes, what type of visa do you have?
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

Other Background Information  
Other names your records may be found under
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
Where did you hear about Butler?

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)