Withdrawal Form

SSL

Student is withdrawing from Belhaven University and all registered classes for this term.  Please complete this form.  Grades, if applicable, will be assigned according to the dates given on the Academic Calendar.

* Indicates required field.

Withdrawal Form for Term: * If other, please specify
Today's Date: *    
Date of latest attendance in any class *    
Belhaven ID# * Social Security # *
Student's First Name * Last Name *
Home Phone * Cell Phone
 
Local Address
Street Address * City *
State * Zip *
 
Permanent Address (if other than Local Address)
Street Address City
State Zip
Reason for Withdrawal *
 
Course Schedule
Course # Course Title Professor

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

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