APPLICATION FOR ADMISSION AND ACADEMIC SCHOLARSHIPS



NOTE: Please turn off your computers pop-up blockers under settings before submitting the online application.

Before registering for classes the following documents will be required:
First time entering freshman:
Official HS transcript or GED scores,
Immunization record, and
ACT or Accuplacer test scores.
Transfer student:
Official college transcript (from all colleges attended),
High school transcript (if less than 18 earned college hrs),
Immunization record, and
Test Scores (if less than 30 earned college hrs.).
Transient student:
Immunization record, and
Letter of Good Standing (unless classes require placement or Prerequisite course; transcript needed).

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 Please do not enter slashes or dashes)

   
       

Gender

Ethnicity - Please select YES OR NO in all fields.

 

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?

 

Are you an Veteran?  

   

Are you an dependent of a Veteran?  

   

Are you a first generation college student? 

   

Are you foreign born?  

   

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?

 

Which campus do you wish to attend?

 

 Will you be enrolled in high school or  are you
currently seeking a degree or certificate at another
institution while attending BRTC? 
If yes, where?  

 

V. Educational Background

High School Name

High School City

High School State


High School/GED graduation date (MMDDYYYY Please do not enter slashes or dashes)
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

Telephone   Number


Home Phone
(Example: 9185551234)

  

I certify that the information on the application is correct. I understand that giving false information or withholding information could make me ineligible for admission at Black River Technical College. 

 

.
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 institution 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 institution.

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