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 AND ENROLLMENT INFORMATION
NAME
PEOPLE SOFT NUMBER
GENDER (OPTIONAL)
_______________________
MALE
FEMALE
SSN
DATE OF BIRTH
_________________________ ____ ______________________________
First
MI
Last
_______________________
__________________________
VA EDUCATION BENEFIT
Post 9/11, Chapter 33 ______________%
Dependent
Spouse
GI Bill Active Duty, Chapter 30
GI Bill Selected Reserve, Chapter 1606
Vocational Rehabilitation, Chapter 31
Reserve Educational Assistance Program, Chapter 1607
Survivors and Dependents Assistance, Chapter 35
A Claim number (Ch 35 only) _____________________
V
CONTACT INFORMATION
PITT E-MAIL ADDRESS ____________________________________
Address______________________________________________________
ALTERNATE E-MAIL
____________________________________
City_________________________ State_______ Zip Code____________
TELEPHONE
____________________________________
DEGREE SEEKING
TERM (Circle One)
TERM
CALENDAR YEAR
CREDITS
Undergraduate
Graduate
Post-Baccalaureate
FALL/SPRING
Certificate only
PHD
Other ________________
SUMMER
PROGRAM
SCHOOL _____________________
DECLARED MAJOR ________________________
FOR OFFICE USE
LAST DUTY STATION/RESERVE UNIT __________________________
IN STATE
OUT OF STATE
BRANCH OF SERVICE
__________________________
YELLOW RIBBON
PITT GRANT
LAST PAY GRADE
__________________________
NOBE/COE
DD214
STUDENT GROUP ____________
PART 2 – DISCLOSURE READ & INITIAL STATEMENTS, SIGN & DATE
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
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
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
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.
____________________________________________________ Date_________________
Signature

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