2011-2012 New Student Worksheet (Military & Veteran Enrollment Services)

2011-2012

Military &

NEW STUDENT WORKSHEET

Veteran Enrollment Services

 Male

 Female

1. NAME (first, middle, last)

2. SEX

3 Social Security Number

4a. CHECK MAILING ADDRESS (Number, street or rural route, city or PO,

5a. Home Phone Number

5b.Work / Cell Phone Number

State and Zip Code)

(

)

(

)

6. Date of Birth

7. Email Address

4b. PERMANENT MAIL ADDRESS

9a. Marital Status

9b. Number of Dependents (exclude self)

 Single  Married

 Divorced

8. In Case of Emergency Contact:

9c. Spouse’s Name

9d. Is Your Spouse a Veteran?

 Yes

 No

10a. Service Dates (Beginning and Ending)

10b. Branch of Service

10c. Are You Eligible for New York Veteran Tuition

Awards/ HESC, or NY National Guard or NY Naval

 Yes

 No

Militia Tuition Scholarships?

11a. Do You Have a Medical Condition? (Service Related)

11b. Have You Established Service

11c. What Percent Disability Are You Receiving?

Connected Disability?

 Yes  No  Unsure

 Yes  No  Unsure

11d. Have You Applied for VA Vocational Rehabilitation?

11e. VA Claim Number (if known)

11f. VA Office Where Records Are Located

 Yes  No  Need Additional Information?

12a. Have You Received VA Educational Benefits Previously?

12b. Are You Still Receiving VA

13. At What School Did You Last Receive VA Education

Benefits?

Benefits?

 No  Yes  From ________ To ________

 Yes  No

($

) Monthly Rate / Chapter (

)

14. EDUCATIONAL BENEFITS YOU ARE APPLYING FOR:

DD-214 must accompany all requests for benefits. Additional required forms are listed below.

 A.

ACTIVE MONTGOMERY GI BILL (CHAPTER 30) – EDUCATION BENEFIT

PROGRAM – SERVICE BEGINNING ON OR AFTER JULY 1, 1985,

 E.

DIC, REPS, OR VA Pension Benefits

THROUGH PRESENT

 F.

VA DISABILITY COMPENSATION OR PENSION

 B.

VA VOCATIONAL REHABILITATION (CHAPTER 31),

 G.

SEL. RESERVE GI BILL (CHAPTER 1606) – (if checked, attach DD 2384)

20% Service Connected Disability or more, VA Form 28-1905 attached.

SLRP  No  Yes SMP  No  Yes

 C.

POST 9/11 GI BILL (NOT CHAPTER 33 YELLOW RIBBON)

 H.

RESERVE EDUCATIONAL ASSISTANCE PROGRAM (CHAPTER 1607)

Provide total number of qualifying active duty days after 09/11/2001(

)

REAP, SLRP, SMP (if checked, attach DD-214 and DD-2384)

 D.

SURVIVOR’S AND DEPENDENT’S EDUCATIONAL ASSISTANCE

(CHAPTER 35), (if checked, complete items 15a and 15b).

15. COMPLETE ONLY IF ITEM 14D IS

NAME OF PARENT (VETERAN)

PARENT’S VA FILE NUMBER

CHECKED

C #

 No  Yes

16a. I Applied to RIT as a :

16b. Accepted?

16c. My University ID Number is:

16d. My Degree Program is:

st

 1

 Transfer

 Graduate

Year

(

)Transfer credits

17. I am attending RIT at the following campus….(please check one)

 HENRIETTA CAMPUS

 ONLINE LEARNER

 OTHER __________________________________

18. PLEASE FORECAST THE NUMBER OF CREDITS YOU PLAN TO TAKE IN THE ACADEMIC YEAR 2011-2012

FALL TERM (20111)

WINTER TERM (20112)

SPRING TERM (20113)

SUMMER TERM (20114)

Enter Credit Hours:_________

Enter Credit Hours:_________

Enter Credit Hours: _______

Enter Credit Hours: ________

Co-op Payment?  Yes  No

Co-op Payment?  Yes  No

Co-op Payment?  Yes  No

Co-op Payment?  Yes  No

 Yes  No

 Yes  No

 Yes  No

 Yes  No

Deferment?

Deferment?

Deferment?

Deferment?

Notice

: Your RIT veteran records will be maintained in Military & Veteran Enrollment Services (MVES) to verify your veteran status with the Registrar;

the total amount of VA Educational Benefits to Financial Aid, and to implement the RIT Veteran Tuition Deferment with Student Financial Services.

Personal information will remain confidential and will be released, only as you authorized below.

I understand that I must report any changes in my enrollment to MVES, to prevent an overpayment of my veteran education benefits (

)

Information Release Authorization: I hereby authorize the release of my Veteran file information to the following individuals. By releasing my information to “ANYONE,” all

persons with a need to know will have access. You can deny all access to your files, by selecting “NO ONE” or, you can specify a single person access. Ask, if this is unclear

or you have any questions.

 ANYONE (on a need-to-know basis)

SIGNATURE

DATE

 NO ONE

 Specifically: _______________________________________

MVES USE ONLY

DD 214

22-1993a

DA 2171

DD 2384

22-1990

22-5490

22-1995

22-5495

28-1905

Rem

FIN

SFS

KICKER

MVES

/ COE

/ COE

Ent

AID

Code

REQUIRED

ON FILE

REMARKS: