APPLICATION FOR ADMISSION


READ CAREFULLY -----
It is recommended that you print this form in order to keep a copy for your files. If you do not want this information sent over the Internet you may print the form and mail it to:

Black River Technical College
Office of  Admissions
PO BOX 468
Pocahontas, AR  72455
Phone : 870-248-4000
Fax : 870-248-4100

Online Application for Admission Fill out all fields below.  Use the Tab key on your keyboard to move between fields.

Before registering for classes the following documents will be required:
First time entering freshman:
Copy of driver's license,
Official HS transcript or GED scores,
Immunization record (if born on or after Jan. 1, 1957), and
ASSET, ACT, SAT or COMPASS test scores.
Transfer student:
Copy of driver's license,
Official college transcript (from all colleges attended),
High school transcript (if less than 18 earned college hrs),
Immunization record (if born on or after Jan. 1, 1957), and
Test Scores (if less than 30 earned college hrs.).
Transient student:
Copy of driver's license and
Letter of Good Standing (unless classes require placement or Prerequisite course; transcript needed).
Concurrent student
High school letter of good standing. 

I. Identification Information

NOTE:  In order to apply electronically, the applicant's Social Security number must be provided.

Social Security Number
(Example: 123456789)
How did you learn about the BRTC?

 

II. Personal Demographic Information

Name

   
First Name 

    
Middle Name 

    
Last Name
 Suffix
       


Maiden Name
   

Address


Permanent Address 

  
     
 


Mailing Address

    
 
 


City


  State


Zipcode

 
 
County		  
  Country		  I have lived in the indicated county for 6 months or more. Check for yes
       

Telephone   Number


Home Phone
(Example: 9185551234)

 
  Work Phone
  (Example: 9185551234)

       

E-mail Address

 Optional 
       

 

III. Request for Confidential Information

Date of Birth


(MMDDYYYY)

    
       

Gender

Ethnicity

 

Are you a US Citizen? 

   
   If you are not a U.S. citizen, give type of U.S. visa held or to be obtained  

Are you an Arkansas resident 

   

Have you lived in Arkansas more than 6 months?

 

Do you have a felony conviction?

 

If yes, what type.

  
 

 

IV. Educational  Information

Seeking admission as:

This application is for

What is your intended Program/Major?

(Non-degree seeking students are NOT eligible for Federal/State Financial Aid.)

  

Which campus do you wish to attend?

 Will you be enrolled in high school or another institution while attending BRTC? 
If yes, where?  

 

V. Educational Background

High School Name

High School graduation / GED date (MMDDYYYY)
Have you attended another College or Post Secondary Institution?
If No skip the following section:.
 

List All Colleges/Post Secondary Institutions Attended

Hours
Completed

Institution City State From M/Y To M/Y

VI. Emergency Contact Not In The Household

Name of nearest relative not in home.

   
First Name 

    
Middle Initial  

    
Last Name
Relationship
       

Address


Address 

  
 
 


City


  State


Zipcode

 

Telephone   Number


Home Phone
(Example: 9185551234)

  

By submitting this application, I affirm that the information is complete and correct.  I understand that submission of inaccurate information can be cause for terminating my enrollment at BRTC.

I hereby certify that all information supplied is complete and accurate.  I understand that I shall not be considered for full or unconditional admission to BRTC until I have submitted all documentation specified.  I understand that withholding information requested or giving false information may make me ineligible for admission and enrollment.  I understand that to be eligible for enrollment at any public institution of higher education within the State of Arkansas, I must register, or be exempt from registration, with the Selective Service System as specified in Act 228 of the 1997 Arkansas General Assembly.  I swear or affirm under penalty of perjury that I have registerd with the Selective Service System, or I am exempted from such registration. 

 
.
Affirmative Action Statement.  In Keeping with the guidelines on Title VI, Section 601, Civil Rights Act of 1964, Title IX, Section 901, Education Amendments of 1972, and Section 504 of the Rehabilitation Act of 1973, this school assures that no person in the United States, shall on the basis of race, color, national origin, sex, or handicap be excluded from participation in, be denied the benefit of, or be subjected to discrimination under any program or activity administered by the school.

COMPLIANCE: COORDINATOR:                                                Jim Ulmer, Black River Technical College
                                                                                                       P.O. Box 468, Pocahontas, AR  72455

 

When you have completed the Online Application for Admission, click the "Submit" button ONE TIME ONLY.