Va Enrollment Certification Request - Drop Add Form printable pdf download

VA Enrollment Certification Request & Drop/Add Form

Office of Veteran Affairs • OKALOOSA-WALTON COLLEGE

Name _____________________________________________________

SSN / File # ___________________________________

Address ___________________________________________________

Tele # _______________________________________

City/State/Zip ______________________________________________

Circle One:

Fall

Spring

Summer

Year ________

❑Address Changed?

If checked please notify the Dept. Veterans Affairs by phone or the “WAVE” at

What is your Program of Study ( Degree Program )? A.A. / A.S. / A.A.S. / Cert

___________________________________________________________

( If POS is different from your last VA Certification submit VA Form 22-1995/5495 and new POS. )

If eligible, pre-certified for the academic school year? ❏ Yes ❏ No

Do you graduate THIS semester at OWCC? ❏ Yes ❏ No

Chapter Befints:

❏ Veteran ( Ch. 30 )

❏ Active Duty ( Ch. 30 )

❏ VEAP ( Ch. 32 )

❏VA Voc Rehab ( Ch. 31 )

❏ Reservist ( Ch. 1606 )

❏ Dependent (Ch. 35)

❏ VA Work Study?

❏Transient Student

❏Dual Enrolled Student

From which institution? __________________________________________________

List only courses on POS you want certified.

If you have Mitigating Circumstances please provide documentation for VA.

Session

Course

Reference

Credit

DROP

ADD

Number

Hours

Course

Reference

Course

Reference

Credit

Number

Hours

I certify that I have read the “Notice” on the reverse side of this form and must submit this request EVERY semester to receive VA Benefits.

Signature _____________________________________________________

Date __________________________

An Equal Access/Equal Opportunity Institution

4/03

NOTICE TO STUDENTS RECEIVEING VA EDUCATION BENEFITS

I understand that all courses must apply toward my current OWC program, and that I must

report any changes to the OWC VA Office. I may also be required to submit a program change

to the VA. I understand that if I do not have a current program of study on file in the OWC VA

Office it may cause delay in my certification. I understand that if I withdraw from classes and

receive a non-punitive grade, I could be liable to the VA for an overpayment of benefits. You

must submit this request EVERY semester to receive VA benefits.

As a recipient of VA Educational Benefits it is your responsibility to familiarize yourself with all

related information contained in the College Catalog, the Student Handbook, and other directives

issued or information released by the College. Failure to meet these responsibilities can result in

the loss of your educational benefits.

The OWC VA Office needs your assistance and cooperation if it is to serve you effectively.

NOTE: NOTIFY THE OWC VA OFFICE AND DEPARTMENT OF VETERANS AFFAIRS

IMMEDIATELY OF ANY CHANGE IN YOU VA STATUS. THE VA TOLL FREE NUMBER IS 1–888–

GIBILL–1 OR (1–888–442–4551).

Va Enrollment Certification Request - Drop Add Form

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