Request for Supplemental Certificate
ALABAMA G.I. DEPENDENTS SCHOLARSHIP PROGRAM
VETERAN IDENTIFICATION
Name:
VA File #:
SECTION I -- STUDENT IDENTIFICATION
Name:
SSN:
Address:
Phone:
(City, State, Zip)
SECTION II -- SCHOOL DATA
A. (1) The new school you are requesting to transfer to:
(2) Date you expect to enroll:
(3) If a technical course, give NAME and LENGTH of new course:
(Signature of Student)
Date
SECTION III -- SCHOOL CERTIFICATION (This section must be completed by an official at the school
reflected on the students last Certificate of Eligibility prior to submission to the Department of Veterans Affairs.)
I certify that the following information includes the dates of attendance and the accompanying hours for
all semesters that the above named student has been/will be billed for under their current certificate for the
Alabama G.I. Dependents Scholarship Program. Additional signed pages may be attached as needed:
Inclusive Semester Dates Hours Billed Inclusive Semester Dates Hours Billed
Inclusive Semester Dates Hours Billed Inclusive Semester Dates Hours Billed
Inclusive Semester Dates Hours Billed Inclusive Semester Dates Hours Billed
(Signature of School Official)
(Official Title) (Phone)
(Print School Name)
SECTIONIV--
EMAIL or FAX COMPLETED REQUEST TO:
supplementalrequests@va.alabama.gov
FAX: 334-353-4078
Allow 30 Working Days Processing Time
ADVA-5s
09/2019
Email:
