Prince Georges Community College printable pdf download

PRINCE GEORGE'S COMMUNITY COLLEGE

VA BENEFITS REQUEST

SPRING, 2012 SEMESTER

Student ID______________________

Please READ AND COMPLETE ALL ITEMS. Print clearly!

1. Social Security Number_____________________________________

2. VA File Number___________________________________

(

Chapter 35 recipients must include suffix)

3. Program of Study_______________________________________________

4. Date of Birth________________________________

NOTE: You must be degree-seeking (in an approved program of study) to receive VA benefits. VA regulations support registration only for

those courses listed in the college catalog as necessary for the completion of the curriculum that you have declared. Only those courses, or

courses required by the college as prerequisites to those courses, will be certified for payment of benefits.

5. Name____________________________________________________________________________________________________________

Last

First

Middle

5. Street Address _____________________________________________________________________________________________________

. City _______________________________________________ State _______________ Zip __________________

Is this a new address? ___Yes ___No Be advised that this address will be used to update your address in the college’s files as well as for

the VA and may impact your tuition charges if it is in another county or state.

6. E-mail Address _________________________________________________________________

7. Home Phone (_________)_______________________________

Work Phone (_________)_____________________

8. ARE YOU ON ACTIVE DUTY?________________

If YES, will you be receiving tuition assistance for any portion of your classes? ____

9. INDICATE THE TYPE OF BENEFITS THAT YOU WILL BE RECEIVING:

________Chapter 30 (Montgomery GI Bill)

________Chapter 33 (Post 9/11 GI Bill)

________Chapter 35 (Dependent of Service Connected Disabled or Deceased Vet)

________Chapter 1606 (Reserve / National Guard)

________Chapter 1607 (REAP) (Reserve / National Guard)

________Chapter 31 VA Vocational Rehabilitation ________________________________ (Name of Case Manager)

Required

10.

INDICATE YOUR VA STATUS:

________ New VA Student (never used any type of VA educational benefits in the past at ANY institution)

________ Continuing Student (enrolled at PGCC during Fall term, using VA benefits)

________ Returning Student (used VA benefits last at PGCC but not during the Fall term).

________ Transfer Student (last used VA benefits at another institution – Submit form 22-1995 or 22-5495 {Chapter 35} and See Below)

________ Supplemental VA Student (visiting student taking classes to transfer back to your home college – Written authorization from

home college is required.

VA regulations require that all transfer students using VA benefits must have transcripts from previous colleges, including military

transcripts, forwarded to PGCC for evaluation of transfer credit. A Request for Evaluation of Transfer Credit form must be completed to initiate the

evaluation of your transcripts after all transcripts have been received. Failure to have your transcripts evaluated during your first or second semester

may cause the VA to stop payment of your VA benefits. Have transcripts sent to:

OFFICE of ADMISSIONS & RECORDS

PRINCE GEORGE'S COMMUNITY COLLEGE

301 LARGO ROAD

LARGO, MD 20774

Please complete the other side.

An Error or Omission May Delay Your Benefits

Prince Georges Community College

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