Veteran Request For Enrollment Certification Form

Veteran Request for Enrollment Certification

Please Return to: Purdue University, Veteran Success Center

Please indicate semester and year

Purdue Memorial Union, Room 284- 286

you wish to be certified for:

101 N Grant St; West Lafayette, IN 47906-3574

Fall _____ Spring _____ Summer ______

Phone: (765) 494-7638 Fax: (765) 494-1545 Email:

dogtags@purdue.edu

Year: ______________

NAME: _____________________________________________________ SSN/VA File# ____________________________

Mailing Address: _______________________________________________________________________________________

Phone: ___________________ eMail: _____________________________ PUID: __________________________________

Which VA Education Benefit Program are you requesting to be certified under this semester?

______ (Chapter 1606)

Montgomery (Reserve/National Guard) GI Bill

______ (Ch1607/REAP) Montgomery (Reserve/National Guard Active Duty) GI Bill

______ (Chapter 30)

Montgomery (Active Duty) GI Bill

_____ (Chapter 31) Vocational Rehabilitation

______ (Chapter 33)

Post 9/11 GI Bill

______ (Chapter 35)

Spouse/Dependent of Veteran (DEA) GI Bill, VA Claim Number: _________________

1. Have you ever been certified under this VA Education Benefit Program before? _____ Yes_____ No

If yes, what institution? ______________________________________________________________________________

What is your current Degree objective? ___________________ Major_________________________________________

Have you changed majors since your last VA enrollment certification? _____ Yes _____ No *If yes, you must meet with

the VA Certifying Official to complete a CODO signature form.

Effective Jan 2015, The DOD has prohibited the use of FTA in combination with Ch. 1606 & 1607 GI Bill. Do you intend to

use MilitaryTuition Assistance for this term? _______Yes _______No *If you continue with the GI Bill claim, you will

need to cancel your request for FTA, if FTA remains, your GI Bill claim will be terminated.

How many credit hours are you enrolled in for the semester requested? _____________* Only courses that apply toward

your current degree objective can be certified under GI Bill.

Are you repeating any classes? _____Yes

______ No Which ones? _________________________________________

Are you participating in any Distance or Independent Study course offerings this term? _____Yes _____ No

Please list any classes you have enrolled in that do not last the full length of the semester? ___________________________

__________________________________________. Classes that do not meet for the length of the semester are only included

during the period they meet. The VA will exclude them during the rest of the semester when deciding how much you will be

paid. NOTE: Enrollment dates may vary for these courses and as a result, payment may be different than expected.

**ALL COURSE WORK MUST BE REQUIRED FOR THE DEGREE IN ORDER TO USE VA BENEFITS

**FOR ALL FAILING GRADES, THE INSTRUCTOR WILL BE CONTACTED FOR LAST DATE OF ATTENDANCE

Change in course enrollment after certification has been submitted to the VA may result in the retroactive loss of benefits unless the

VA finds mitigating circumstances involved in the change. Loss of benefits could revert back to the first day of class.

I AM AWARE THAT CHANGES IN MY REGISTRATION MAY ALTER THE PAYMENT THE VA WILL AWARD ME. I

understand that I will be liable for any overpayment I might receive from the Veterans Administration. I also understand that I must

notify the VA Certifying Official of any changes in registration.

I AM ALSO AWARE THAT I MUST FILL OUT THIS FORM EACH SEMESTER AFTER REGISTERING FOR CLASSES. I

hereby certify that all statements are true and complete to the best of my knowledge and belief.

_________________________________________________

____________________________________

SIGNATURE

DATE

12/01/2014

Veteran Request For Enrollment Certification Form - 2014

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