Va Form 22-8889 - Application For Educational Assistance Test Program Benefits

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OMB Approved No. 2900-0383
Respondent Burden: 30 minutes
1. VA FILE NUMBER (If known)
2. VA OFFICE WHERE RECORDS ARE LOCATED
APPLICATION FOR EDUCATIONAL ASSISTANCE
(If known)
TEST PROGRAM BENEFITS
(Section 901, PL 96-342)
PART I - APPLICANT
IMPORTANT: Before completing this form read the Information and Instructions on the reverse. Type or print answers in ink. If
additional space is required, attach separate sheets and key answers to item numbers. If you are on active duty, Part II must be
completed by your Commanding Officer (CO.)
3. NAME OF APPLICANT (First, middle, last)
4. SOCIAL SECURITY NUMBER
5. MAILING ADDRESS (Number and street or rural route, city or P.O., State and ZIP Code)
6. DATE OF BIRTH
7. TELEPHONE NO.
(Month, day, year)
(Include Area Code)
8. VA BENEFITS PREVIOUSLY APPLIED FOR
B. SURVIVORS' AND DEPENDENTS' EDUCATIONAL ASSISTANCE (38 U.S.C. Chapter
A. EDUCATION OR TRAINING BASED ON YOUR OWN
MILITARY SERVICE (38 U.S.C. Chapter 30, 31, 32, 34 or
35(If checked, complete Items 8F and 8G below.)
10 U.S.C. Chapter 1606, formerly Chapter 106)
E. OTHER
C. DISABILITY COMPENSATION OR PENSION
D. NONE
(Specify)
F. NAME OF PARENT
G. PARENT'S FILE NUMBER
COMPLETE ONLY IF BOX
8B IS CHECKED
9. DID YOU RECEIVE AN INFORMATION PAMPHLET ENTITLED "SUMMARY OF BENEFITS
THE EDUCATIONAL ASSISTANCE TEST PROGRAM" FOR SECTION 901 OF PUBLIC LAW 96-342?
YES
NO
10. SERVICE INFORMATION
NOTE: Attach Copy 4 (or any other available copy) of your DD Form 214 for each completed period of active military service. Complete Items 10A
through 10E for any period for which you cannot attach a DD Form 214. In all instances, you MUST COMPLETE ITEM 10F.
(See instruction number 4 on reverse.)
DATE ENTERED
DATE SEPARATED FROM
TYPE OF SEPARATION OR DISCHARGE
GRADE OR RANK
BRANCH OF SERVICE
ACTIVE DUTY
ACTIVE DUTY
C.
D.
E.
A.
B.
PRESENT MILITARY
G. BRANCH OF
F. ARE YOU NOW ON ACTIVE DUTY?
SERVICE
STATUS
YES
NO
(If "Yes," complete Item 10G and have you CO complete Part II)
11. PROGRAM OF EDUCATION AND ENROLLMENT INFORMATION
B. DESCRIBE THE COURSE YOU WILL BE TAKING (List each degree
A. WHAT IS THE FINAL EDUCATIONAL, PROFESSIONAL, OR VOCATIONAL GOAL YOU
or vocational course)
PLAN TO REACH THROUGH THE PROGRAM FOR WHICH YOU ARE APPLYING? (Highest
degree or occupation)
C. DATE YOUR PROGRAM WILL BEGIN (Month, day, year)
D. NAME AND MAILING ADDRES OF SCHOOL (Include ZIP Code)
12. REMARKS
I HEREBY CERTIFY THAT all statements made herein are true and complete to the best of my knowledge and belief, and I
herewith apply for a program of education under EATP (Educational Assistance Test Program.)
13A. SIGNATURE OF APPLICANT (DO NOT PRINT)
13B. DATE SIGNED
SIGN HER IN
INK
PENALTY: Willfully false statements as to a material fact in a claim for education benefits is a punishable offense and may result in
the forfeiture of these or other benefits and in criminal penalties.
PART II - CO'S CERTIFICATION OF SERVICE FOR INDIVIDUALS ON ACTIVE DUTY
I CERTIFY THAT the records of this individual, who is under my command, are correct, and I verify the accuracy and completeness
of the service and type of discharge or separation shown in Item 10.
14A. SIGNATURE OF CO OR DESIGNEE
14B. UNIT
14C. DATE
VA FORM
EXISTING STOCKS OF VA FORM 22-8889, APR 2001,
22-8889
JUL 2012
WILL NOT BE USED.

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