Veteran’s Certification Request

Your Information

Name

Student ID

Address

City

State

Zip Code

Phone

Semester

VA Benefit

Select your VA Education Benefit?

Chapter 33 (Post-9/11 GI Bill^®)

If Chapter 33, Eligibility Percentage?

Chapter 30 (Montgomery GI Bill^® Active Duty)

Chapter 1606 (Montgomery GI Bill^® Selected Reserve/NG)

Chapter 1607 (Reserve Educational Assistance Program)

Chapter 35 (Dependents Education Assistance Program)

If Chapter 35, VA file number?

Marine Gunnery Sergeant John David Fry Scholarship

Chapter 31 (Vocational Rehabilitation and Employment)

If Chapter 31, 1905 expiration date?

GI Bill^® is a registered trademark of the U.S. Department of Veterans Affairs (VA). More information about education benefits offered by VA is available at the official U.S. government website at www.benefits.va.gov/gibill.

Academic Program Information

(Your program must agree with that listed in the University’s official record)

Current Degree Program

Course 1

Course Title

Course ID

Section

Session

Campus Location

Course 2

Course Title

Course ID

Section

Session

Campus Location

Course 3

Course Title

Course ID

Section

Session

Campus Location

Course 4

Course Title

Course ID

Section

Session

Campus Location

Course 5

Course Title

Course ID

Section

Session

Campus Location

Course 6

Course Title

Course ID

Section

Session

Campus Location

Course 7

Course Title

Course ID

Section

Session

Campus Location

Course 8

Course Title

Course ID

Section

Session

Campus Location

Course 9

Course Title

Course ID

Section

Session

Campus Location

Electronic Signature

VA File Number

If you are human leave this field blank

The completion of this form authorizes the School Certifying Official to certify my enrollment and provide academic record information to the Department of Veteran Affairs to ensure the receipt of Educational Training Benefits. I understand that I must complete this form each semester to receive benefits. It is my responsibility to notify the Veterans Certification Department immediately upon adding, dropping or withdrawing from a course.