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VA Request for Certification

TERM/YEAR: /

STUDENT IDENTIFYING INFORMATION

FULL NAME (Student)
STREET ADDRESS
CITY & STATE
ZIP CODE
PHONE NUMBER
E-MAIL ADDRESS
VA FILE # / SS# (Veteran)^*
SOCIAL SECURITY # (Student)
DATE OF BIRTH
^*if you are using dependent benefits

PROGRAM NAME & MAJOR

VETERAN BENEFIT INFORMATION

I am claiming the following benefit: (Select One)

Chapter 30 Montgomery GI Bill – Current/Former Active Duty

Chapter 31 Vocational Rehabilitation & Employment Program

Chapter 33 Post-9/11 GI Bill

Chapter 33 TEB Transfer of Eligibility (for spouse/dependent using the TEB program)

Chapter 35 Survivors’ & Dependents’ Educational Assistance

Chapter 1606 Montgomery GI Bill – Selected Reserve/National Guard

Chapter 1607 Montgomery GI Bill – Reserve Educational Assistance Program (REAP)

Are you currently on Active Duty?

Completion of this form authorizes the Cleary University Records Department to certify my enrollment and provide academic record information to the Department of Veterans Affairs to initiate processing of educational training benefits. I understand that I must complete this form EACH SEMESTER before my enrollment will be certified, and that submission of the certification does not guarantee payment of benefits. It is my responsibility to notify the Records Department immediately upon adding, dropping or withdrawing from a course, and I understand that the Records Department will also report and changes to my enrollment status.

I HAVE READ AND UNDERSTAND THE ABOVE POLICIES AND PROCEDURES.

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Your legal name

Your email address

Please Confirm full name and signature.

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October 29, 2020 4:12 pm EDT

VA Request for Certification Uploaded by Michael Thompson - michael@yourppl.com IP 75.128.132.184