Veterans Affairs (Va) Education Assistance printable pdf download

Veterans affairs (Va) education assistance

NAME _________________________________________________________________________________

Last

First

Student ID Number

academic information

______________________________________________________________________________

___________________________________________

Degree



Major (is this a change?

Yes

No)

contact information

______________________________________________________________________________

___________________________________________

Street

Preferred Phone Number

______________________________________________________________________________

___________________________________________

Zip

City

State

VCU Email Address

1. For which semester(s) are you seeking certification? Semester: ______________

Year: _____________

2. Are you currently on Active Duty?  Yes

 No

3. Do you have a VA file number?

 Yes

 No If yes, it is _____________________________________

4. Which education assistance program(s) or chapter(s) do you intend to use?

 Chapter 30 (GI Bill)

 Chapter 35 (Survivors and Dependents)

 Greater than three years of service

 Chapter 1606 (Selective Reserve/National Guard)

 Less then three years of service

 Chapter 1607 (Reserve Educational Assistance Program)

 Chapter 31 (Vocational Rehabilitation)

 Consecutive service of 90 days but less than one year

 Number of dependents ________

 Consecutive service of one year +

 Chapter 32 (Veterans Educational Assistance Program)

 Consecutive service of two years +

 Chapter 33 (Post 9/11 GI Bill)

 Virginia Military Survivors and Dependents Education Program

 Chapter 33 Post 9/11 GI Bill Transferability (Dependent)

5. Would you like to be considered for Yellow Ribbon benefits?

 Yes

 No

6. Are you eligible for a kicker? If so, how much is your monthly kicker? $ _________

7. If you are eligible for the MGIB and paid to enhance your basic entitlement, how much did you pay? $ __________

8. Have you received VA Education Assistance before?

 Yes

 No If yes, when did you last receive it? _______________________________________

9. Have you used VA Education Assistance at another school?

 Yes

 No

If yes, please provide a copy of your VA Certificate of Eligibility and Request for Change of Program or Place of Training (VA form 22-1995).

10. Are you using a Tuition Assistance Program to pay for courses?

 Yes

 No

11. Are you using a Faculty/Staff Tuition Waiver to enroll in courses?  Yes

 No

12. List the classes in which you are enrolled and have an academic advisor certify that these courses will count toward your degree or certificate program.

course reference

course

section

is this an online, noncredit remedial, deficiency,

credits

number

subject

number

repeat, audited or residency training course?

summer sessions begin and end dates

If you registered for additional classes, attach another completed VCU Veterans Affairs (VA) Education Assistance form. You will only be certified for the classes listed and

approved by your academic advisor.

academic advisor: I certify that the courses listed in the chart are prerequisites or are required for the degree or certificate program the student is pursuing.

_________________________________________

_____________________________________

Advisor’s printed name

Advisor’s signature

Date

certification statement: I certify that the information provided on this form is true and correct. I attest that I have read the information on this form and will abide by its content.

_______________________________________________________

_____________________________________

Student’s signature

Date

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