Prospect Data Entry Form

Thank you for your interest in Barton Community College! Please enter your information below so we can send you information about your Barton opportunity!

- indicates a required field.

Entry Term
Term of Entry:

Let's start with your name. Please enter in upper and lower case (such as Jane Doe).

Name
Prefix:
First Name:
Middle Name:
Last Name:
Suffix:
Nickname:

We want to tell you about the many opportunities Barton has to offer you! Please enter your address and phone number so we can send information and keep you updated on your areas of interest.

Note: The "Valid From" field is automatically today's date and please leave the "Until" field blank.

Address
Valid From:	Month Day Year (YYYY)
Until:	Month Day Year (YYYY)
Address Line 1:
Address Line 2:
Address Line 3:
City:
State or Province:
ZIP or Postal Code:
County:
Nation:
Phone Number:	- (xxxxxx)-(xxxxxxxxxxxx) (xxxxxxxxxx extension)
International Access Code:

Date of Birth
Date of Birth:	Month Day Year (YYYY)

If available, please enter your social security number below. This is a secure web site and your SSN is used for information and processing purposes only. Barton is committed to your privacy and confidentiality. Submitting your SSN is voluntary, but will eventually be required if applying for federal aid.

Prospect SSN/TIN/TFN
U.S. Social Security Number:	(999999999 or 999-99-9999)

Please enter your primary e-mail address. Barton will not send you unwanted e-mail and will not provide e-mail addresses to outside agencies.

E-Mail Address
E-mail Address:
Verify E-mail Address:

Please indicate your gender below. Gender information is used strictly for sending interest information, reporting purposes, and is confidential.

Gender
Gender:	Male	Female	Not Specified

If your high school is not found in the "look up high school code" button, provide as much information as possible in the high school fields below. If you are or were home schooled, please check the "Home Schooled" box.

High School Information
Home Schooled (check for yes):
OR
High School Code:
High School Name:
Address Line 1:
Address Line 2:
Address Line 3:
City:
State or Province:
ZIP or Postal Code:
Nation:
Graduation Date:	Month Day Year (YYYY)
Class Rank and Size:	/ (must be numeric)
GPA:	(example: 9.99, or A+)

Please enter your primary academic major of interest.

Program of Study
Major:

Tell us about your interests. To select multiple interests use Ctrl+Click for PC and Command+Click for Mac. Available only at the Great Bend campus.

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Barton County Community College