Request For Change Of Program Or Place Of Training Form
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4OMB Approved No. 2900-0074
Respondent Burden: 12 minutes
REQUEST FOR CHANGE OF PROGRAM OR PLACE OF TRAINING
For Veterans, Servicepersons, & Members of the Selected Reserve
1. VA FILE NUMBER AND/OR SOCIAL
IMPORTANT: Please read the attached instructions before completing this form. Please type or use ink to complete the
SECURITY NUMBER
form. If you need more space, use the back of this form and write the item number next to your answer.
2. FIRST-MIDDLE-LAST NAME OF APPLICANT
3A. HOME TELEPHONE NO.
3B. WORK TELEPHONE NO.
(Include Area Code)
(Include Area Code)
4. MAILING ADDRESS (No. and address or rural route, city or P.O., State and
5. ANSWER ONLY IF YOU’RE A FEDERAL GOVERNMENT
EMPLOYEE: DO YOU EXPECT TO RECEIVE EDUCATIONAL
ZIP Code)
BENEFITS UNDER THE GOVERNMENT EMPLOYEE’S
TRAINING ACT FOR THE SAME TIME YOU WILL RECEIVE
VA EDUCATION BENEFITS?
YES
NO
YOUR PROGRAM
6. WHAT EDUCATION, PROFESSIONAL OR VOCATIONAL GOAL ARE
7. WHAT’S THE NAME OF THE PROGRAM YOU’RE REQUESTING?
YOU WORKING TOWARD? (Highest degree or occupation)
(Specific degree, major, certificate, diploma)
8. HOW WILL YOU TAKE THIS TRAINING?
SCHOOL ATTENDANCE
APPRENTICESHIP
INDEPENDENT STUDY
OR ON-THE-JOB TRAINING
DISTANCE LEARNING/INTERNET
CORRESPONDENCE
COOPERATIVE TRAINING
FLIGHT TRAINING
9A. NAME AND ADDRESS OF YOUR NEW SCHOOL OR TRAINING
9B. NAME AND ADDRESS OF YOUR OLD SCHOOL OR TRAINING
ESTABLISHMENT (Include city, State, and ZIP Code)
ESTABLISHMENT (Include city, State, and ZIP Code)
10. TELL US WHEN AND WHY YOU STOPPED TRAINING AT YOUR PRIOR SCHOOL OR ESTABLISHMENT.
CURRENT DEPENDENCY INFORMATION
ANSWER ONLY IF YOU’RE RECEIVING CHAPTER 30 (MGIB) BENEFITS AND SERVED ON ACTIVE DUTY BEFORE JANUARY 2, 1978.
11A. ARE YOU CURRENTLY MARRIED?
12. HOW MANY DEPENDENT CHILDREN DO YOU CLAIM?
YES
NO
11B. SPOUSE’S NAME
13. DO YOU CLAIM ANY PARENTS AS DEPENDENTS?
YES
NO
CURRENT ACTIVE DUTY INFORMATION
14. ARE YOU NOW ON ACTIVE DUTY?
YES
(IF "YES," GIVE DATE ACTIVE DUTY BEGAN)
NO
(IF "NO," GO TO ITEM 16A)
15. DO YOU EXPECT TO RECEIVE EDUCATIONAL BENEFITS FROM THE ARMED FORCES OR PUBLIC HEALTH SERVICE DURING ANY PART
OF YOUR TRAINING?
(BE SURE TO HAVE YOUR EDUCATION SERVICE OFFICER COMPLETE ITEM 17.)
YES
NO
CERTIFICATION AND SIGNATURE OF APPLICANT
I HEREBY CERTIFY THAT all my statements on this form are true and complete to the best of my knowledge and belief.
PENALTY: Willful false statements as to a material fact in a claim for educational benefits is a punishable offense and may result in forfeiture of these and other
benefits, and in criminal penalties.
16A. SIGNATURE OF APPLICANT (Do Not Print)
16B. DATE SIGNED
CERTIFICATION NEEDED FOR PERSONS ON ACTIVE DUTY
(THIS ITEM DOESN’T APPLY TO SELECTED RESERVISTS OR VETERANS NOT ON ACTIVE DUTY.)
I CERTIFY THAT this individual is a member of the Armed Forces and has consulted with me regarding his or her education program.
17A. SIGNATURE, TITLE, AND BRANCH OF SERVICE OF EDUCATION SERVICE OFFICER
17B. DATE SIGNED
VA FORM
EXISTING STOCK OF VA FORM 22-1995, MAR 2000,
22-1995
MAY 2002
WILL BE USED.
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