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OMB Control No. 2900-0073

NOTE: Tear off and read the Instruction and Certification Sheet before completing the form.

Respondent Burden: 10 minutes

Side

VA ENROLLMENT CERTIFICATION

IMPORTANT: Side A is for Institutions of Higher Learning or schools offering non-degree training.

(First, Middle, Last)

(For chapter 35, include suffix. For Transferability

1. NAME OF STUDENT

2. VA FILE NO.

cases, enter the veteran's social security number)

3. CURRENT ADDRESS OF STUDENT

(If not entered in

4. SOCIAL SECURITY NUMBER OF STUDENT

Item 2)

5. TYPE OF TRAINING

6A. NAME OF PROGRAM

UNDERGRADUATE COLLEGE DEGREE

FARM COOPERATIVE

(For VA

6B. IS STUDENT MATRICULATED AT YOUR FACILITY?

purposes, a student is matriculated when formally admitted as

GRADUATE OR ADVANCED

a degree seeking student)

HIGH SCHOOL

PROFESSIONAL

(Not Farm)

YES

COOPERATIVE

NON-COLLEGE DEGREE

6C. IS PARENT SCHOOL LETTER ON FILE?

GUEST STUDENT

(Supplemental School)

YES

(Complete Item 6C)

7. YELLOW RIBBON RECIPIENT

YES

ENROLLMENT DATA

9. COURSES TAKEN

13. TRAINING

10. CLOCK

12. YELLOW

8. ENROLLMENT EFFECTIVE

CREDIT HOUR COURSE(S)

NON-CREDIT

11. CHARGES

TIME

DATES

HOURS

FOR PERIODS

RIBBON

(Graduate or

TAKEN BY

REMEDIAL/

(Month, Day, Year)

PROGRAM

TAKEN

PER WEEK

OF INSTRUCTION

Advanced

DISTANCE

DEFICIENCY/

IN-RESIDENCE

Professional

LEARNING

REFRESHER

Program)

A. HOURS

A. BEGIN

B. END

B. HOURS

C. HOURS

HOURS

A.TUITION

B. FEES

AMOUNT

14. ADDITIONAL INFORMATION FOR HIGH SCHOOL AND FARM CO-OP COURSES

(Enter the number of high

(Is student pursuing course concurrently with substantially

A. HIGH SCHOOLS APPROVED ON A UNIT BASIS

B. FARM CO-OP ONLY

school units for which the student is enrolled)

full-time agricultural employment averaging at least 40 hours per week?)

YES

ADVANCE PAYMENT REQUEST - (Note: Advance payment is not accelerated payment.) (See Special Instructions.)

15A. SIGNATURE OF STUDENT

15B. DATE SIGNED

I REQUEST AN

ADVANCE PAYMENT

ACCELERATED PAYMENT REQUEST

(Note: Accelerated payment is not advance payment.) (See Special Instructions.)

I request accelerated payment. I certify that I intend to seek employment in one of the following industries: Biotechnology, Life Science Technologies,

Opto-electronics, Computers and Telecommunications, Electronics, Computer-integrated Manufacturing, Material Design, Aerospace, Weapons, or

Nuclear Technology.

16A. SIGNATURE OF STUDENT

16B. DATE SIGNED

I REQUEST AN

ACCELERATED PAYMENT

17. REMARKS

NOTE - Complete Item 18 only if course(s) are contracted out to another school or are given at a branch location other than shown in Item 19B. Do not

complete Item 18 if course(s) are taken at a branch or extension of a school as defined in 38 CFR 21.4266(c).

18. NAME AND ADDRESS OF CONTRACT SCHOOL OR BRANCH LOCATION

CERTIFICATIONS - The provisions described in paragraphs (1) through (14) on the attached sheet are certified.

19A. FACILITY CODE

19B. SCHOOL NAME AND ADDRESS

19C. TELEPHONE NUMBER OF CERTIFYING OFFICIAL

19D. SIGNATURE OF CERTIFYING OFFICIAL

19E. DATE SIGNED

VA FORM

22-1999

SUPERSEDES VA FORM 22-1999, DEC 2007,

MAR 2009

WHICH WILL NOT BE USED.

Va Form 22-1999 - Instructions And Certifications For Va Enrollment Certification (Va Form 22-1999) Page 3

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