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BCIS Advisor Request

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Instructions:  This form is best viewed with the Internet Explorer browser.  Complete this form in its entirety, then click "Submit" at the bottom of the page.

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Student and Contact Information  
  * Student First Name:  
  * Student Last Name:  
* Are you a prospective student with no student ID?
No, I AM a CURRENT student, or I HAVE a student ID.
Yes, I am a PROSPECTIVE student with NO student ID.
  * Student ID Number:  
  * Student Email Address:  
  * Contact Phone:  
In the format of: 555-555-5555  		   ext.  
  * What is your birth date?:    ,  
  * Where are you now?:     
  * Where are you going?:     
  * Intended Major or Degree Plan:   
  
Advisor Request Information  
  * Issue you would like to discuss:  
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  * When would you like your appointment 
(First Preference):  		  ,  
  * At what time on this first preferred date?:   :
  * When would you like your appointment 
(Second Preference):  		  ,  
  * At what time on this second preferred date?:   :
  * When would you like your appointment 
(Third Preference):  		  ,  
  * At what time on this third preferred date?:   :
  * Check this box to confirm consent of release:  Check this box to confirm consent of release
I understand that all records, activities, and communications related related to the advising process will be kept confidential within the constraints of state and federal law. I understand the College will abide by all state and federal regulations regarding the privacy of student records and comply with the Family Education Right to Privacy Act (FERPA) and the Buckley Amendment of 1974 regarding access procedures. FERPA is a federal law that protects the privacy of student education records.

I further understand and agree that the College may use any data collected for research purposes. In all products or publications produced from this research, I understand all personal identifying information will be removed.  
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NorthWest Arkansas Community College, One College Drive  Bentonville, AR (479) 63-NWACC (479-636-9222).
We also have locations in Washington County and Bella Vista.
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