Adult and Graduate Education Application for Admission

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Welcome to the online application for the Jackson, Atlanta, Chattanooga, Dalton, Houston, Memphis, Orlando and Rome, GA Adult and Graduate Programs at Belhaven University. 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.

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:
Check here if you have less than the required minimum one year work experience with the same employer.

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)

Electronic Signature Required:

* I hereby affirm to the best of my knowledge that all information on this form is complete and accurate and that any omission or misrepresentation may result in denial to the program, loss of credits, and/or dismissal from Belhaven University. I authorize Belhaven University representatives to request and receive from all schools I have previously attended (or am attending) copies of my academic records upon filling out the transcript request form. If enrolled, I agree to abide by all the policies of Belhaven University including, but not limited to, those represented in the catalogue and student handbook; I also give Belhaven University 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:		Yes No

Belhaven University 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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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:
How did you hear about Belhaven?
Other Source:
Religious Affiliation:

If your name will appear in any other form on transcripts and documents, enter that name here:

High School Graduate or GED?:		YesNo
Graduation year:

I plan to start program in: Month:		Year:

I plan to attend classes in:		Atlanta Chattanooga Dalton Houston Jackson Memphis Orlando Rome, GA

Gender	Ethnicity and Race Information	Marital Status

Male Female	Are you of Hispanic/Latino ethnicity or descent? Yes Select one or more races with which you identify yourself: American Indian or Alaska Native Asian Black or African American Native Hawaiian or Other Pacific Islander White	Single Married Divorced Separated Widow

Have you taken the Praxis I?		Yes No
Have you taken the Praxis II?		Yes No

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

Adult and Graduate Education Application for Admission

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

Please list your current or most recent employer.

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

For Federal Reporting Purposes:

Electronic Signature Required: