One University Drive
Orange, CA 92866
va@chapman.edu
VA Student Responsibility Form
The VA Student Responsibility Form cannot be accepted via fax or in person.
Download the VA Student Responsibility Form to your computer and e-mail it as an attachment to va@chapman.edu.
PERSONAL INFORMATION
Student ID (if known):
VA Claim #:
C
Male
Female
/
/
Social Security Number:
Date of Birth:
Optional, unless you are planning to apply for Financial Aid, then it is necessary.
Full Legal Name:
Last
First
M.I.
Address:
City:
State:
ZIP:
Primary Phone Number:
Chapman E-mail:
MILITARY STATUS
What is your current military status:
Veteran
Reservist
Active Duty (Currently Serving)
Dependent
If you are a dependent, are you receiving a Transfer of Entitlement?
If Yes, from a:
Spouse
Parent
BENEFITS STATUS
Please indicate the benefit/s you intend to utilize this semester and, if applicable, the percentage for which you’re qualified by clicking the box below.
Attach to this form all supporting documentation (e.g. Certificate of Eligibility; Tuition Assistance Application).
Chapter 33−Post 9/11 GI Bill: __________%
Chapter 1607−Reserve Education Assistance Program (REAP)
Chapter 35−Survivors and Dependents Educational Assistance
Yellow Ribbon Program
Spouse or Parent File # or SSN# ______________________________
Chapter 30−Montgomery GI Bill
Tuition Assistance
Chapter 31−Vocational Rehabilitation
Chapter 1606−Montgomery GI Bill
Other:
BRANCH OF SERVICE
Check boxes for all branches of service that apply:
Air Force
Army
Navy
Coast Guard
Marine Corps.
Army National Guard
Air National Guard
DEGREE OBJECTIVE
Choose your degree objective:
Bachelor of Arts
Bachelor of Science
Bachelor of Fine Arts
Bachelor of Music
Master of Arts
Master of Business Administration
Master of Science
Master of Fine Arts
Doctoral (Ph.D.)
Doctor of Physical Therapy
Expected Graduation Date:
Term (Spring, Fall)
Year
Major or Academic Program:
Second Major or Academic Program, if applicable:
Signature on Page 2 is required.
rev. 4/2013