VA Certification Request Form

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Signature: Required. VA EDUCATION BENEFIT to be used in certification on VA 22-1990 form (As APPLIED for VA EDUCATION BE
Registrar’s Office

Veterans ENROLLMENT CERTIFICATION REQUEST

Veterans Affairs WWW Link: http://www.gibill.va.gov/ Return signed, completed forms to the Registrar’s Office. This form must be submitted for EACH term for which you wish to receive VA Education Benefits.

□ UG Career □ Graduate Career

Major:

Name: First

GU ID:

Middle

Check here if you are on Active Duty

Last VA File Number (If Assigned by VA):

SSN:



Campus PO Box:

Permanent Address on VA File:

Date:

Email:

Signature: Required

VA EDUCATION BENEFIT to be used in certification on VA 22-1990 form (As APPLIED for VA EDUCATION BENEFITS):

o o o o

Chapter 30 (Montgomery GI Bill - Active Duty - MGIB)

o o

VA Yellow Ribbon

Chapter 32 (VEAP-Contribution Program) Chapter 33 (Post 9/11 GI Bill) Chapter 33 Yellow Ribbon Eligible …Student Must provide Official VA Eligibility Certificate AND must apply for GU participation Info re: Chapter 4 Education and Training

Eligibility Certification attached

VA Vocational Rehab Benefits

o o o

Attaching VA Certificate of Eligibility (COE)

o

Chapter 35 (Dependent of disabled/deceased veteran) :

o o o

Federal Military Tuition Assistance (TA)

Attaching Gallaudet YR Participation Application Check here if you are a Post-9/11 TEB Recipient (dependent)

Chapter 1606 (Montgomery GI Bill - Selected Reserve) Chapter 1607 (Reserve Education Assistance Program)

Check here if you were ever academically dismissed from Gallaudet □

LIST ALL COURSES FOR WHICH YOU ARE CURRENTLY REGISTERED: Do you expect to make any scheduling changes? □ YES □ NO Course Code (i.e. BIO)

Course Title

Course Credits

Student’s VA certification Agreement – Due before your VA 22-1999 can be processed and enrollment certified. I certify that all courses are applicable to my study program and meet VA requirements. I agree to promptly notify Gallaudet – Registrar’s Office as well as the Veterans Administration of any changes with my credit hours or attendance at GU for the stated enrollment period/semester. I understand that completion of this Gallaudet VA form assures me of enrollment certification with the Department of Veterans Affairs, but does not guarantee payment from the VA. Payment depends on my being enrolled in an approved program, my not owing money to the VA for overpayment, and my compliance with all other VA regulations. I further understand that any information on this form or in my academic record may be shared with the VA at its request. Signature:

Date:

NOTE: You must contact the Registrar’s Certification Official Office by email if you make changes to your enrollment after the Schedule Adjustment Period. Changes to Enrollment after the add/drop period (by calendar dates may affect receipt of VA Education Benefits. For Registrar’s Use Only: Credits: Dependent?

2012

Units: Awaiting CoE ?

Grad Status: Percentage: Tuition:

Fees:

Active duty? Any Remedials? Date:

Initials: