Veteran Benefit Authorization Form
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1Veteran Benefit
Authorization Form
You should only complete this form once per term immediately after registering for courses if:
you are a veteran, active duty military, reservist, national guard, or a dependant of a veteran and
you are eligible for and plan to use one of the VA education benefits listed below.
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STUDENT NAME: ___________________________________New Student:
yes
no Guest Student:
yes
no
ID or SS#:_______________________________________ Email_______________________________________
Phone #________________________________Degree Program: ______________________________________
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Please check only one term:
Fall 2014
Jan Plan 2015
Spring 2015
Summer 2015
Please check the VA education benefit program you plan to receive for the indicated term:
□ Chapter 30
– Regular Active Duty Education Assistance
□ Chapter 33
– Post 911 Education Assistance
□ Chapter 31
– Disabled Veterans Vocational Rehabilitation and Employment
□ Chapter 1606
– Selected Reserve Education Assistance
□ Chapter 1607
– Reservist Educational Assistance
□ Chapter 35
– Veterans’ Survivors and Dependents Educational Assistance
Chapter 35 VA File Number:________________________________
□ Other: _____________________________ (e.g. VRAP, Chapter 32, Selection 903, 901, REPS, etc.)
I certify that all of the information I have provided on this form is accurate to the best of my knowledge, and I understand
that it is my responsibility to notify the Finger Lakes Community College Financial Aid Office (by completing a Veteran
Change in Enrollment form) of any changes to my course schedule.
I understand that if I choose not to attend this semester I should follow the proper withdrawal procedure by submitting a
completed Withdrawal Form to the Educational Planning and Career Services Office. I also understand that proper
withdrawal before the semester start date will negate my financial obligation to the college, withdrawal on or after the
first day of the semester will result in a financial obligation to either the college, the VA, or both.
I authorize Finger Lakes Community College to certify my military education benefits with the Veterans Administration.
Student Signature: ___________________________________
Date:_____________________
New Applicants, Transfer and Guest Students:
In addition to this Veteran Registration Form please provide copies of the following documents:
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Copy of the veteran’s DD214
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Certificate of Eligibility
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Request for Change of Program or Place of Training (VA Form 22-1995) required for transfer students and
degree changes (veterans)
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Request for Change of Program or Place of Training Survivors’ & Dependants’ Education Assistance (VA Form
22-5495) required for transfer students and degree changes (Chapter 35 recipients)
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Primary School Letter (guest students only)
If you have any questions you can contact the School Certifying Official at: Finger Lakes Community College
3325 Marvin Sands Dr.
Canandaigua, NY 14424
(P) 585-785-1276
(F) 585-394-0635
Official Use Only
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CRI ________________________
DADD____________________
Certification complete_____________________
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Employee Initial)
Employee Initial)
Employee Initial
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