Va Form 22-1990e - Application For Family Member To Use Transferred Benefits Page 4

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PART III - EDUCATION AND EMPLOYMENT INFORMATION

(If "Yes," specify below)

10A. DO YOU HOLD ANY FAA FLIGHT CERTIFICATES?

YES

(Including apprenticeship, on-the-job training, and flight training)

10B. EDUCATION AFTER HIGH SCHOOL

NUMBER AND

NAME AND LOCATION OF

DATES OF TRAINING

DEGREE, DIPLOMA, OR

MAJOR FIELD OR

TYPE OF HOURS

COLLEGE OR OTHER

(Semester, Quarter

CERTIFICATE RECEIVED

COURSE OF STUDY

TRAINING PROVIDER

FROM

or Clock)

(Only complete if you held a license or journeyman rating to practice a profession)

10C. EMPLOYMENT

EMPLOYMENT

PRINCIPAL OCCUPATION

NUMBER OF MONTHS WORKED

LICENSE OR RATING

JOB 1 SINCE HIGH SCHOOL

JOB 2 SINCE HIGH SCHOOL

PART IV - ENTITLEMENT TO AND USAGE OF ADDITIONAL TYPES OF ASSISTANCE

11A. FOR APPLICANTS ON ACTIVE DUTY ONLY: Are you receiving or do you anticipate receiving any money

YES

(including but not limited to Federal Tuition Assistance)

from the Armed Forces or Public Health Service

for the course for which you have applied to the VA for education benefits?

11B. FOR APPLICANTS WHO ARE CIVILIAN EMPLOYEES OF THE U.S. GOVERNMENT ONLY:

(including but not limited to the Government

Are you receiving or do you anticipate receiving any money

YES

Employees Training Act)

from your Agency for the same period for which you have applied to the VA for

education benefits? If you will receive such benefits during any part of your training, check "YES."

PART V - SERVICE MEMBER INFORMATION

12. SERVICE MEMBER'S SOCIAL SECURITY NUMBER

13. SERVICE MEMBER'S BRANCH OF SERVICE

(First, Middle Initial, Last)

14. SERVICE MEMBER'S NAME

15. SERVICE MEMBER'S ADDRESS

Number and Street

Apt./Unit Number

City, State, ZIP Code

PART VI - CERTIFICATION AND SIGNATURE OF APPLICANT

I CERTIFY THAT all statements in my application are true and correct to the best of my knowledge and belief. If on active duty, I also certify that I

have consulted with an Education Service Officer (ESO) regarding my education program.

PENALTY - Willful false statements as to a material fact in a claim for education benefits is a punishable offense and may result in the forfeiture of

these or other benefits and in criminal penalties.

16A. SIGNATURE OF APPLICANT (DO NOT PRINT)

16B. DATE SIGNED

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VA FORM 22-1990E, DEC 2016