So, you wanna know more about us. . .

The request information form will ask for personal information such as name, address, e-mail address and for your intended major and activities of interest.  Fill out as much of the information as you can so the Admissions Office can fulfill your request as completely as possible.  Information such as social security number is optional and is not needed for any request.  Thank you for your interest in Coffeyville Community College.

First Name:    Middle Name:   Last Name:

Birth Date (MM/DD/YYYY): / /

Address: 

City: 

State: 

Zip Code: 

Home Telephone:  ()  - 

E-mail address: 

Year of High School Graduation: 

High School:   

Major Field of Study: 

Activities of Interest:
Check all the activities that interest you.  You will also have an opportunity to list activities not listed below.

Agriculture Art Athletic Training
Band Baseball Basketball, M.
Basketball, W. Cheer Choir
Theatre Football Sport Manager - Which Sport? 
Golf Softball Track/Cross Country
Horticulture Volleyball Rodeo
Men's Soccer Women's Soccer Communications/Broadcasting
Livestock Judging Native American Club Dance
Quiz Bowl        

Other Activities of Interest Not Checked Above: 

Technical Areas of Interest:
With the recent merger of Coffeyville Community College and SEK Technical School, a number of technical programs are now available for CCC students.  If you are interested in a technical program, please check below.

Automotive Business and Computers
Collision Repair Computer Networking
Construction Computer Aided Design
Electrical PC Repair
Precision Machine Welding
EMT/Paramedic Web Design

   Yes, this information is correct.  (Required) Please check this circle once you have double-checked the information provided for accuracy.

(After pressing the submit button, please be patient for the form to be processed.  This process may take a minute or two.  Once the form is processed, you will be directed to a confirmation page).