Va Intent Form - Transferred Benefits

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VA Intent Form – Transferred Benefits
Bowling Green State University
email: vabenefits@bgsu.edu
Registration and Records
110 Administration Bldg
Bowling Green, OH 43403
Phone: 419-372-9636
Fax: 419-372-7977
Use this form if you
a military member and are using transferred veterans benefits.
ARE NOT
Name _____________________________________________
BGSU ID ___________________________
Address ____________________________________________
SSN ___________________________
(Address for VA benefit check – permanent address preferred)
City
_____________________ State ______ Zip __________
Home Phone ____________________
Email __________________________________________________
Cell Phone ____________________
This is my first semester receiving VA benefits
Yes
No
If yes, a 22-1990e ( ) has been submitted to the VA
If no, list the name of the school where you last submitted for benefits: _________________________________________________
Student Status:
Undergraduate
Graduate
Guest/Primary School _______________________
Degree/Major _______________________________________
Minor ______________________________
I am graduating this semester
Chapter
33 (Post 9/11)
35 (Survivor / Dep Ed Assist) VA File # _________________
33 (Post 9/11 – Fry Scholarship)
Year
________________
Fall
Spring
Summer
Course Section & Number
Dates of Enrollment
Credit Hrs
Example: HIST 2010 / 1001
Example: August 26 – December 20, 2013
3
Total Credit Hours
0
The courses which I have listed above, and registered for, are required for my stated degree/major and have not been taken previously nor do I have
transfer credit for them. I will notify the VA office, BGSU, should I move or make any schedule or credit hour changes. I authorize the release of my
academic transcripts to all parties to determine the
continued use of my VA benefits.
______________________________________________________________________
__________________________
Signature
Date
Office Use:
R
/
G
/
% /
TOE
/
DEA
/
FRY
/
NR ____

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