Adult and Graduate Education Application for Admission


ABOUT SSL CERTIFICATES

Welcome to the online application for the Jackson, Orlando, Memphis, and Houston Adult and Graduate Programs at Belhaven College. Please completely fill out this application and click the SUBMIT button at the bottom of the page to get your college application moving. An admission counselor will contact you upon receipt of your online form. Please note that information on your application fee payment will be provided once your online application is submitted. We are excited that you are applying to Belhaven and we look forward to serving you as you grow academically and spiritually.

First Name:  
Last Name:  
Middle Name:  
Maiden Name:  
SSN:   (xxx-xx-xxxx)
Date of Birth:  
     
Street Address:  
City:  
State:  
Zip Code:  
     
Home Phone #:  
Work Phone #:  
Cell Phone #:  
Email Address:  
     
If your name will appear in any 
other form on transcripts and 
documents, enter that name here:		  
     
High School Graduate or GED?:  
Graduation year:  
     
I plan to start program in:  Month:   Year:
     
I plan to attend classes in:   Houston  Jackson  Memphis  Orlando 

 

List all post secondary institutions attended and degrees earned (ie, colleges, universities,etc.)

Institution Location Dates Degree Hours

 

Please list your current or most recent employer.

Employer Name:  
Employer Address:  
Position Title:  
    Full Time Part Time
Length of Employment:  

 

I plan to utilize the following resources to cover my educational costs (check all that apply):

Self-Payment Financial Aid
Employer reimbursement Employer direct payment
      (percentage or amount paid by employer)
Veterans’ Benefits (contact the VA Representative at your campus for eligibility requirements)
Other (please specify)

 

For Federal Reporting Purposes:

The following information is optional and does not affect the admission process.  It is used for statistical purposes and to provide information required by the U.S. Department of Education in accordance with applicable federal regulations.  An answer in each category would be appreciated.

Country of Birth:  
Country of Citizenship:  
Country of Residence:  

Gender: Racial/Ethnic Marital Status














Electronic Signature Required:

* I hereby affirm to the best of my knowledge that all information on this form is complete and accurate. I authorize Belhaven College representatives to request and receive from all schools I have previously attended (or am attending) copies of my academic records. If enrolled, I agree to abide by all the policies of Belhaven College including, but not limited to, those represented in the catalogue and student handbook; I also give Belhaven College permission to send and supply news, photos and honors to my hometown newspaper and college publications.


Applicant's Legal Signature:  
    (Type full name)
Today's Date:  
Agreed acts as your signature:  

Belhaven College is committed to a policy of non-discrimination on the basis of race, color, sex, religion, handicap, age, or national/ethnic origin.

Once you submit this application, an admission counselor will be contacting you to let you know of any other necessary items to complete the admission process. Print a copy of this form for your records before pressing "submit."


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