Returning Student VA Education Benefits Certification Form
Complete, the attached form with a copy of your class schedule to the Veteran Center for certification
Name:___________________________ ______________________________ ____________ SSN:_______________
Last
First
MI
Address: ________________________________________ ______________________________ ______ __________
Street
City
Branch: U.S. Coast Guard
Military Status: Please Select
State
Zip Code
Student ID: ____________ Phone:______________
VA Program _________________ E-mail:[email protected]
(Example: Chapter 33)
DEA Chapter 35 File # _________________ Alternate email:________________________________________
Associates Degree of:
Arts
Science
Applied Science
Nursing
Certificate Program
Major / Program of Study: __________________________________________ Catalog Year: _____________
(This must be identical to major with the Enrollment Services Office)
Answer the following Questions Yes or No:
1. Did you receive any Punitive or Non Punitive Grades (X, W, I, or F Grades) in the previous semester?
2. If you had a W grade, did you turn in a signed VA Student Class withdraw form to the Certifying Official?
3. Have you changed your program of study since last semester? If YES, please submit the change in writing.
4. Do ALL courses on your class schedule meet graduation requirements for you program of study?
4.
Have
4.
you
6. Outside of GI Bill benefits, have you arranged for payment of your tuition? (FASFA, or payment plan)
Have
atten
4.
you
ded
7. Are you using any tuition only scholarships or Tuition Assistance? If yes, please list ____________________ Have
atten
other
4.
you
ded
8. Are you graduating at the end of this semester?
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Have
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other
4.
es? If
you
ded
I (Name) __________________________________ certify that the information reported to the SJC Certifying Official
on
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Have
YES
atten
other
this form are accurate and true statements. I am acknowledging my responsibility to notify the SJC Certifying Official
es?
If
you
what
ded
in writing if enrolling in a course previously certified, making changes to my class schedule / program of study.colleg
YES
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other
es?
If
Furthermore, I understand I must submit an instructor verified last day attended date if I stop attending or withdraw
what
ded
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YES
from my classes during the semester to the Certifying Official. In addition, I understand if I fail to report changes
in my
schoo
other
____
es?
If
what
enrollment status to the Certifying Official I could receive overpayments and incurred debt from the VA.
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____
YES
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____
es?
If
____
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____
Student Signature: ________________________________ Date_________________
l____
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Years
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:
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Years
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:____
5. Do any of your registered courses have a course number of 050 to 099? (Example Math 095)