Va Enrollment Certification Form
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1VA ENROLLMENT CERTIFICATION
(Complete each quarter and return to the LA Tech VA Certifying Official, Sheila Sanchez)
**Failure to turn in this form each quarter may delay benefits. **
Personal Information
Name ______________________________________________________SS # _____________________
Address _____________________________________________________________________________
Street
City/State
Zip Code
E-mail Address ___________________________________ Phone # ____________________________
Enrollment Information
Degree/Major __________________________________Qtr/Yr you plan to graduate _____________
This certification is for
Fall _____ Winter _____ Spring _____ Summer _____ Year _____
List all courses enrolled in for this quarter that are counting toward your degree program/major.
Course Name and Number
Hours
On-line? (yes or no)
Remedial? (yes or no)
TOTAL NUMBER OF HOURS
_____ I agree to report any enrollment changes to the VA Certifying Official.
_____ I certify that I have not received prior credit for any course for which I am registered this quarter.
_____ I understand that the Veterans Administration will not award benefits for courses which are not
credited toward my degree program; nor for courses for which I have previously earned credit, unless required
by Louisiana Tech University.
Chapter of Benefits
I am requesting benefits for the following chapter:
_____Chapter 30: Montgomery GI Bill (MGIB)
_____Chapter 35: Survivors and Dependents Benefit*
_____Chapter 31: Vocational Rehabilitation
_____Chapter 1606: National Guard/Selected Reserve
_____Chapter 32: VEAP
_____Chapter 1607: Selected Reserve Active Duty
_____Chapter 33: Post 9/11 GI Bill
If Chapter 35, indicate VA file # here: _________________
*
History of Your VA Benefits
If you are a continuing VA student at Tech, please sign below and turn in.
If you are one of the following please check one, sign below and complete the back of this form, page 2.
Transfer Student
New Student
Visiting Student
Readmitted Student
_____________________________________________________________
_________________________
Student’s Signature
Date
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