TRANSCRIPT REQUEST

PLEASE PRINT To:_________________________________ Date:______________________ Co lleg e

Belhaven University

1500 Peachtree Street Box 268

Jackson, MS 39202

From :______________________________ Date last attended:__________________ _ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ _ SSN#___________________________________

_____

_ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ _ Date of Birth:____________________

A d d r e s s _ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ _ _ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ______ City State Zip Telephone Na m e (s) under which you attended: ___________________________________ _ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ __

Please Pri n t Online Admission

Phone # _____________________________ Address__________________________ _________________________________ _________________________________

Please mail or e-script to:

fax: 601-968-8946

Fax # _______________________________

Student’s Name (Please Print)

Student’s Signature

Number

IMPORTANT: Prior to sending request to Belhaven, please determine if your school accepts credit card payment and faxed transcript requests.

Credit Card Payment _______ Faxed Requests _______