Enrollment Certification Request Form

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Veterans Services
University of Pittsburgh
Office of
1440 Wesley W. Posvar Hall
Phone:
412-624-3213
ENROLLMENT CERTIFICATION REQUEST FORM
Fax:
412-624-4766
veterans@pitt.edu
PART 1 – STUDENT INFORMATION
1. NAME
2. PEOPLE SOFT NUMBER
_________________________ ____ ______________________________
__________________________
First
MI
Last
PART 2 - Enrollment Information
TERM (CIRCLE ONE)
YEAR
CREDITS ENROLLED
FALL / SPRING
SUMMER
IF THIS IS A CHANGE IN CREDITS TO WHAT YOU HAVE PREVIOUSLY CERTIFIED THIS TERM CHECK HERE: ___________
PART 3 – READ & INITIAL STATEMENTS, SIGN & DATE
9. I understand that it is my responsibility to certify for each term for which I plan to receive benefits at the Office of Veterans Services.
________
Initial
10. I understand that it is my responsibility to report any status changes (including add/drop, G, I, or W grades, address change, change
________
of major or school, or any other changes that may affect my entitlement to G.I. Bill benefits).
Initial
11. I understand that I am responsible for any debt owed to the University of Pittsburgh or Veterans Affairs resulting from an
overpayment in my education benefits. Non-payment may affect my student account and future registration. I understand that GI Bill
________
benefits (Chapter 31 & 33) are only applied to tuition and fees, less any scholarships unless the scholarship is refundable.
Initial
12. I, the undersigned, certify that the above statements are true to the best of my knowledge. I have read and understand my responsibilities as
outlined above. I will report any and all status changes to Office of Veterans Services as soon as they occur.
___________________________________________________________ __________________
Signature
Date
CONTACT INFORMATION (if changed)
FOR OFFICE USE ONLY
Address______________________________________________________
NEW STUDENT
YELLOW RIBBON
City_________________________ State_______ Zip Code____________
IN STATE
OUT OF STATE
Telephone____________________________________________________
PITT GRANT
PROGRAM INFORMATION (if changed)
VA Form 22-1995 must be completed
SCHOOL ______________________ MAJOR_______________________

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