Veterans Intake Form Sierra College
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1
2Veterans Intake Form
Name (Last, First, Middle Initial)
Last, First, MI
Chapter Benefit
Chapter 30 - Montgomery G.I. Bill
Veteran SSN XXX-XX-XXX
123-45-6789
Student SSN (if same as above enter
123-45-6789
'Same")
900-00-0000
Student ID number (XXX-XXX-XXX)
Phone number (XXX)-(XXX)-(XXXX)
(321) 123-4545
Address (Street Address include apt#,
123 Madeup Ln, Apt#123, Rocklin, CA, 95677
City, State, Zip)
04/26/2015
Date of intake (Today's date)
E-mail address
Attending Grass Valley Campus?
Yes
No
-------------------------------------------------FOR OFFICE USE ONLY--------------------------------------------------
Applied to Sierra College
Complete
Yes
DD-214 On file
No
Coded for Chapter
P
D
V
CA Residency Cleared
Yes
No
College Transcripts (List Schools)
Complete VA Form 22-1990
Complete
Complete VA Form 22-1995
Complete
Complete VA Form 22-5490
Complete
Complete VA Form 22-5495
Complete
Cal-Vet Fee Waiver
Yes
No
Submit copy of NOBE (Ch. 1606 only)
Complete
Submit Certificate of Eligibility (COE)
Complete
Veteran Orientation (Date Attended)
Appointment with Veteran Counselor
Yes
No
English__________
Assessments
Reading __________
Math__________
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