Revised9/19
Registration&Records275EastlandRoadBereaOH440172088PH:4408262126Fax4408266522
Returning Undergraduate Student Form
(for students who plan to return to BW after a 12-month period)
____________________________________________ _____________________
(Student Name) (Student I.D. #)
________________________________ ________________________ __________________
(Name when last attended BW – if different)* (Email) (Phone)
*Please note: In order to update academic records, name changes require a copy of your Social Security card or Driver’s
License with current information.
________________________________________________________________________________
Home Address City State Zip
Last attended BW: Term: ________________ Year: _____________
What term and year would you like to return to BW: Term: _______________ Year: ___________
Please indicate: Day Division ____ Adult, Transfer & Military Svc. ____ Teacher Licensure ____
Degree Seeking ____ Non-Degree Seeking ____ Certificate Program ____
Indicate Major or Minor for Degree: ___________________________
Other degrees earned: __________________ ______________________________ _________
BA / BS / MBA / MAE Institution Year
Have you attended any other college or university since your last term at BW: Yes ____ No ____
If yes: ____________________________________________ __________________________
(College/University) (Dates Attended)
____________________________________________ _______________
Student Signature Date
*****Email completed form to webregis@bw.edu or mail to address below*****
Do not write below – For OFFICE USE ONLY
Start Term: Catalog: Hours earned: GPA: (3.0 minimum)
Last Attended: I/T: C: F:
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signature
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