Certification Request Form

Certification Request Form

OFFICE OF VETERANS AFFAIRS
NOTE: Please only complete this form if you have attended an Information Session with our VA office.
Have attended and completed an Information Session with our VA office? *

Yes No
Please attend and complete an Information Session with our VA office. Please see the Veterans Affiars Information Sessions schedule.
Name *

First Name Last Name
Student ID Number *
Current Program of Study *
Ex: Marketing Management
Semester *

Spring Summer Fall
Concentration
Ex: Social Media Marketing
Level

Degree Diploma Certification
Post 9/11: *

Yes No
Percentage (%) : *
VA Educational Benefit Used: *
Counselor's Name

First Name Last Name
Chapter 35 ONLY

Complete sponsor name and sponsors SSN
Sponsor Name

First Name Last Name
Sponsor SSN
- List all registered classes on final schedule in the table below
- If you make any schedule changes, you must submit an updated certification request form.
Courses List (Please enter classes you are currently registered for.) *
* Post 9/11 GI Bill (only):
- You are responsible for all charges not paid by the VA. Payment is due by fee payment deadline.
- I understand that by taking only Online Courses I will receive half of the national average BAH.
* Ch 30 (MGIB-Active Duty), Ch 1606 (Reserve/National Guard), Ch 1607 (Activated Reserve/National Guard) only:
- You must verify your attendance at the end of every month at http://www.benefits.va.gov/gibill/ or by phone at 1-877-823-2378
I certify that the above information is correct and that all courses lead to my declared program of study and are not repeated courses.

"I understand that it is my responsibility to report any schedule changes to the Office of Veterans Affairs, and that I must submit this form each term before my class schedule can be certified."
Your E-mail *
We will send you an email receipt once we receive your request form.
Signature *
Date *

Month Day Year
For OFFICIAL USE ONLY
Semester Certification Requested:
Date Certified in VA Once:

Month Day Year
Date
Amount Tuition/Fees Added:
Date Tuition/Fees Added:

Month Day Year
Date
Total Certification Credit:
Date placed on HOLD:

Month Day Year
Date
Date input into BANNER:

Month Day Year
Date
Classes Verified:
COMMENTS:
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Should be Empty:

Certification Request Form

Chapter 35 ONLY

For OFFICIAL USE ONLY