Salutation: Mr Ms.
First Name:
Middle Name:
Last Name:
Previous Names (Please list all names you have used on previous educational records. One full name per line please.)
Previous Names:
Last 4 of SS#
Street Address:
City:
County:
State:
Zip:
Home Phone (includea area code):
Cell Phone (include area code):
Work Phone (include area code):
Date Of Birth (mm/dd/yyyy):
Gender: Female Male
Primary Race/Ethnicity: American Indian/ Alaskan Native Asian Black/African-American Hispanic/Latino Not Specified Native Hawaiian/Other Pacific Islander White
StartingTerm: Fall Summer Spring
Year:
Home Campus: Cooper Danville Georgetown Lancaster Lawrenceburg Leestown Regency
Program of Study:
Classes: (please enter the name(s) of classes you would like to take)
Admit Status: Admit Status: First-time college student (no college coursework taken must submit an official HS transcript/GED scores) High School (taking college courses prior to HS graduation must submit an official HS transcript) Visiting Student (must submit a letter of good standing from your home college) Readmit (attended BCTC previously) First-time Transfer (transcripts from all previously attended institutions are required before admission) Non-degree Seeking (was not enrolled in the previous semester at a University/College)
High School Attended (please give the Name, City, and State):
High School Graduation Date (mm/dd/yy):
Please list all postsecondary institutions attended. Include the name of the College, City, State, and dates attended(an official transcript from each institution listed is required for admission.)
College 1 Name
College 1 Address
College 1 Dates
College 2 Name
College 2 Address
College 2 Dates
College 3 Name
College 3 Address
College 3 Dates
College 4 Name
College 4 Address
College 4 Dates
Unless otherwise indicated, all information on this form must be complete and accurate.
Withholding or providing false information may make you ineligible for admission or enrollment.
You will not be officially admitted to this college until all required credentials are received by this Admissions Office.
If you do not enroll, application materials will be retained on file for one year.
Although there is not an application fee, upon signing this document you acknowledge responsibility for all financial obligations you incur if you enroll as a student in the KCTCS, including any costs associated with the collection of your account.
I authorize Bluegrass Community and Technical College to email my PeopleSoft ID number to a non-KCTCS supported email account.
I understand that my PeopleSoft ID number is used to access my online account that includes academic, demographic, ad financial information regarding my BCTC enrollment history.
Please email my PeopleSoft ID number to:
Date (mm/dd/yyyy):
Signature
