Veterans Certification Request Form - Polk State College
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3VETERAN’S CERTIFICATION REQUEST FORM
(Please submit this form in person, by mail, or via fax transmittal.)
Section I: Student Information
Last Name
First Name
M.I.
Polk State Student ID No.
Address
City
State
Zip
Phone Number
Polk State Email Address
Section II: Student Status (Please answer each question as it applies to you with a Y/N.)
Degree-Seeking at
Seeking Transient Study
Active Duty
Active Reserve
Florida
Polk State College
(If so, list your home
National Guard
college.)
Section III: Academic Information
Term
Academic Year
Primary Major**
**Please note, if changing your declared major, you must complete V.A. form 22-1995 for veterans or form 22-5495
for dependents (Request for Change of Program/Place of Training) and submit it with this form. Chpt. 31 veterans
must contact their case manager and notify the Polk State Student Financial Services Office.
Section IV: V.A. Benefit Chapter (Please choose one.)
Chpt. 30
Chpt. 31
Chpt. 32
Chpt. 33
Chpt. 35
Chpt. 1606
Chpt. 1607
Post 9/11
Survivor’s/
G.I. Bill
REAP
Montgomery
Voc. Rehab.
Veterans
G.I. Bill
&
Ed. Asst.
Dependent’s
Selected
Employment
Program
Ed. Asst.
Reserve
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