Va Form 22-5495 - 2010 Dependents' Request For Change Of Program Or Place Of Training Page 2

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PART IV - YOUR PROGRAM

21A. CHAPTER 35 - SURVIVORS' AND DEPENDENTS' EDUCATIONAL

21B. CHAPTER 33 - POST-9/11 GI BILL MARINE GUNNERY

ASSISTANCE PROGRAM (DEA)

SERGEANT JOHN DAVID FRY SCHOLARSHIP (FRY SCHOLARSHIP)

INSTITUTION OF HIGHER LEARNING

COLLEGE OR OTHER SCHOOL

FARM COOPERATIVE

LICENSING OR CERTIFICATION TEST

APPRENTICESHIP OR ON-THE-JOB TRAINING

NATIONAL ADMISSIONS EXAMS OR NATIONAL

EXAMS FOR CREDIT

(Spouse or Surviving Spouse only)

CORRESPONDENCE

(e.g., Bachelor of Arts in Accounting, Welding Certificate, Police Officer)

22. SPECIFY YOUR EDUCATION OR CAREER OBJECTIVE

23. WHAT IS THE NAME OF THE PROGRAM YOU ARE REQUESTING TO PURSUE?

24. IF CHANGING SCHOOLS, PROVIDE NAME AND COMPLETE ADDRESS OF NEW

25. IF CHANGING SCHOOLS, PROVIDE NAME AND COMPLETE ADDRESS

SCHOOL OR TRAINING ESTABLISHMENT YOU PLAN TO ATTEND

OF CURRENT OR OLD SCHOOL OR TRAINING ESTABLISHMENT

(if applicable)

26. TELL US WHEN AND WHY YOU STOPPED (or will stop) TRAINING AT YOUR OLD (or current) SCHOOL OR TRAINING ESTABLISHMENT

PART V - REMARKS AND CERTIFICATION

(If more space is needed, please attach a separate sheet of paper. Be sure to include name and social security number on each sheet of paper)

27. REMARKS

I CERTIFY THAT all statements in my application are true and correct to the best of my knowledge and belief.

PENALTY - Willful false statements as to a material fact in a claim for education benefits is a punishable offense and may result in the forfeiture of

these or other benefits and in criminal penalties.

28A. SIGNATURE OF APPLICANT (DO NOT PRINT)

28B. DATE SIGNED

Sign Here

In INK

Page 2

VA FORM 22-5495, OCT 2010