Veterans Certification Request - Palm Beach State College
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1
2V
’
C
R
ETERAN
S
ERTIFICATION
EQUEST
N
:
S
ID#
Term: Fall Spring Summer
AME
TUDENT
First
MI
Last
(circle one)
A
:
C
:
Z
:
DDRESS
ITY
IP
P
(
) _______________________
E-
____________________________
HONE NUMBER
MAIL
(C
VA P
)
Check box if this is the FIRST time using benefits & your VONAPP has been submitted online.
HECK
ROGRAM
YOU MUST PROVIDE CERTIFICATE OF ELIGIBILITY.
____C
. 30 (GI B
) _____ C
. 1606 (R
/G
) ______C
. 1607 (REAP) _____C
.32 (VEAP) ____C
. 31 (V
. R
)
H
ILL
H
ESERVE
UARD
H
H
H
OC
EHAB
_____C
. 35 (D
/S
) VA C
# ____________________
Circle one: I am the 1
2
3
dependent to use benefits.
st
nd
rd
H
EPENDENT
POUSE
LAIM
CH. 33 (Post 9/11 GI BILL) ELIGIBILITY PERCENTAGE (
): ________
_____
NEW STUDENTS
■ I last attended Palm Beach State College (please state term/year) ______________________________________________
■ Since your last enrollment, have you changed your program/major?
NO
YES
If, YES, please complete and
attach VA Form 22-1995 for Veterans OR VA Form 22-5495 for Dependents.
ACADEMIC INFORMATION:
(Y
C
’
)
OUR PROGRAM MUST AGREE WITH THAT LISTED IN THE
OLLEGE
S OFFICIAL RECORD
AA/AS/AAS/BAS _____________________________ PSAV/CCC
CURRENT DEGREE PROGRAM
_____________________
(List Program)
(List Program)
L
E
A
______ C
O
A
_____
C
A
_____
F
A
______
AW
NFORCEMENT
CADEMY
ROSS
VER
CADEMY
ORRECTIONS
CADEMY
IRE
CADEMY
P
I
:
LEASE CERTIFY ME FOR THE FOLLOWING COURSES IN WHICH
AM CURRENTLY ENROLLED ON THIS CAMPUS
C
N
C
ID#
H
C
N
C
ID#
H
OURSE
AME
OURSE
OURS
OURSE
AME
OURSE
OURS
E
: N
1
NUR1023
4
XAMPLE
URSING
A
A
C
Exceptions: transient/dual enrolled students submit a transient form from your primary institution.
CADEMIC
DVISOR
ERTIFICATION
Criminal justice (i.e., Law Enforcement, Corrections, or Cross-over) and fire academy students do not need an advisor’s signature.
I hereby certify all the above classes are necessary for the student’s major.
Yes________
No________
If NO, please state: _______________________________________________________________________________
A
’
: __________________________ S
: _____________________ D
: __________________
DVISOR
S NAME
IGNATURE
ATE
The completion of this form authorizes the Veterans Certification Department to certify my enrollment and provide
academic record information to the Department of Veteran Affairs to ensure the receipt of Educational Training Benefits. I
understand that I must complete this form each semester in order to receive benefits. It is my responsibility to notify the
Veterans Certification Department immediately upon adding, dropping or withdrawing from a course.
S
S
:
D
:
____________________________________________________
_____________________________
TUDENT
IGNATURE
ATE
DO NOT submit this form until your registration is complete. Please be sure to read, sign, and submit the Veteran’s
Rev. 11/2011 (2 pages)
Memorandum of Understanding”
Certification “
Page 2 of this form.
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