Application for Certificate Completion

* Indicates required field.

Student's First Name: *
Student's Last Name: *
Student's SS# *
Belhaven ID# *
E-Mail: *
Campus Student Attended: *
I expect to have all certificate requirements completed by: Month: *   Year: *
Select a Certificate Program:
Accounting Health Administration
Biblical Ministry   Human Resources
Biblical Studies Leadership
Dance Sports Administration

Method of Payment:
Note: There is a $25 Certificate Completion Fee.
Credit Card  (Credit card payment can be
    made through a secure server once this
    form has been submitted.)
Money Order

I understand that if I fail to complete all certificate requirements by the date above, I will be required and it is my responsibility to re-submit an Application for Certificate Completion.

Before certificates are officially granted, grades must be recorded and records rechecked for total hours, quality points, and other certificate requirements. This form must be submitted a minimum of 10 weeks prior to certificate completion. Printed certificates will be available a minimum of 4 weeks after certificate completion and will be dated with correlating term end date.

Applicant's Legal Signature: *
  (Type full name)
Today's Date: *
Agreed acts as your signature: Yes  No *

Print a copy of this form for your records before pressing "submit."

Enter the numerical value of ten minus three. *