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 _______