VA Enrollment Certification Request

VA Enrollment Certification Request

To have your classes certified with the VA and receive your Veterans Education Benefits, you MUST complete this form EACH SEMESTER. (Multiple semesters may be included on one form.)
Semester(s)*
Year*
Benefits Chapter
Name*

First NameLast Name
Student ID*
Email*
example@example.com
Phone Number*
Please enter a valid phone number.
I will be graduating this semester.*

YesNo
This semester, I will be attending another college in addition to Panola College.*

YesNo
School Name (if applicable)
Contact Name (if applicable)

First NameLast Name
Contact Phone (if applicable)
Please enter a valid phone number.
Contact Email (if applicable)
example@example.com
I am requesting that my enrollment in the above referenced semester(s) be certified with the Department of Veterans Affairs. I understand that if I drop a class or change my schedule, I MUST notify the SCO in the Charles C. Matthews Foundation Student Center. If applicable, I understand that the VA will ONLY pay in-state tuition and fees and that any portion of out-of-state tuition and fees will be my responsibility.
Signature*

Clear
Date*

MonthDayYear
Date
Should be Empty: