Vrc Form - California State University

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CALIFORNIA STATE UNIVERSITY, EAST BAY – VETERANS AFFAIRS OFFICE, STUDENT ADMINISTRATION BUILDING
25800 CARLOS BEE BOULEVARD, HAYWARD CA 94542 | (510) 885-3669 PHONE | (510) 885-3816 FAX
VETERANS REQUEST FOR CERTIFICATION (VRC) FORM
IMPORTANT: All requested information must be completed and this form signed in order to process your certification. This form
must be submitted to the Enrollment Information Center in the SSA building or emailed to
va@csueastbay.edu
from your Horizon
account. Certification beyond this term is NOT automatic. It is your responsibility to ensure that your benefits continue by submitting
the VRC each quarter by the priority deadline. All correspondence regarding your benefits will be sent to your HORIZON email account.
New Applicants: Always allow the USDVA at least 6 – 8 weeks to process your application and payment.
If you have used benefits previously, please allow the USDVA at least 30 days to process your payment.
NAME:______________________________________________ Net ID:__________ SSN/VA File# ________ -_______ -___________
Last
First
M.I.
TERM (PLEASE CHECK ONE):
Fall
Winter
Spring
Summer
20_____
Type of Benefits:
Chapter 30/34 (Montgomery GI Bill)
Chapter 31 (Voc. Rehab.)
Chapter 32 (VEAP)
Chapter 1606 (Reservists)
Chapter 1607 (REAP)
Chapter 33 (Post-9/11) Veteran
Chapter 35 (Dependents): File # ________________________
Chapter 33 (Post-9/11) TEB-Dependent
CONTACT INFORMATION (Remember to update MyCSUEB!)
DEGREE OBJECTIVE
nd
Address:____________________________________________
BA
BS
2
Bachelor’s Degree
Credential (SS/MS)
City:_____________________ State:______ Zip:____________
MA
MS
MBA
MPA
MSW
Other:__________
Phone #: (
) _________-_____________
Program/Major:_______________________________________
Option (must be formally declared):_______________________
Report address change to VA?
Yes
No
nd
2
Major or Minor: ________________
Changing Major*
I am a:
1.
Continuing Student
NEW/INCOMING:
First Time Freshman
Transfer
Post-Bacc/Graduate Student
I am a(n):
2.
Undergraduate
Unclassified Graduate*
Classified Graduate
OFFICIAL USE ONLY:
Expected quarter of graduation:
3.
Fall
Winter
Spring
Summer
20___
___
Final Quarter
Are your receiving any of the following grants? (Ch. 33 recipients only)
___
Adjusted certification
4.
Date:
Cal Vet/College Fee Waiver
Cal Grant
State University Grant
NONE/No FAFSA
Units:
Reason:
* See Veterans Benefits Coordinator for additional forms required for certification.
WAIT! Have you enrolled in classes? This form must be submitted AFTER you enroll in classes. Incomplete forms will not be processed and will be
returned to the student. You will only be certified for classes in which you are enrolled – these classes must satisfy one or more of the following
degree requirements: General Education, Program/Major, University requirements. If you change your unit load (add/drop/withdraw), you must
notify the Veteran Benefits Coordinator by email at va@csueastbay.edu within one week of any change to your academic situation.
Indicate Requirement:
If this class will be taken at another
- GE (area and number, e.g., B6, D4)
Institution, please indicate the
- Major (core, option, elective)
name of the Institution and attach a
- University (CGW, Code, unit req.)
copy of your proof of enrollment in
Official
Official
Official
Course Number
**must be verified by GE evaluation
this class so that a Parent School
Use:
(e.g., ENGL 1001)
Units
Use:
Use:
and/or major degree plan
Letter* can be sent to the Institution.
Are you repeating any classes?
Yes
No
If yes, list class(es), term(s) previously taken and grade(s) received:___________________________________________
Student Statement of Understanding
I am aware that it is my responsibility to keep the Veterans Affairs Office informed of my true academic situation (i.e., changes in program, units, withdrawal, etc.).
I realize that I am liable for the repayment of benefits awarded through a claim based on false or misleading statements.
Student Signature:___________________________________________________
Date:__________________________
Revised 10/14 DDH

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