Withdrawal Form

Whether you are withdrawing from Belhaven University, withdrawing from your present course only, or withdrawing from multiple courses, you must complete this form.

The information you provide on this form impacts your financial aid, refund (if applicable), and your grades.

* Indicates required field.

Please indicate your student type:
Are you withdrawing from Belhaven University, from all courses this term, or just your present course? *
    (PW) - I wish to withdraw from Belhaven University
    (TW) - I wish to withdraw from all courses in my current term
    (CW) - I wish to withdraw from specific courses in this term
    (CW) - I wish to withdraw from a single course in this term
Withdrawal Form for Term: *
Today's Date: *    
Date of latest attendance in any class *    
Belhaven ID# * Social Security # *
Student's First Name * Last Name *
Primary Phone (Cell Phone Preferred) *
Local Address
Street Address * City *
State * Zip *
Permanent Address (if other than Local Address)
Street Address City
State Zip
Reason for Withdrawal*
Course(s) To Be Withdrawn
Course # Course Title Last Date Attended Professor
* * * *

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