VA Enrollment Certification Request Form
BC3 Student ID#: Phone Number:
BC3 Email Address: (please check regularly):
Major (officially declared): Is this a new major?
Are you currently on Academic Probation or Academic Warning?
Semester Schedule of Courses
Course Name # of credits Repeat? Online Class?
Example: Research Writing 3 NO NO
Military Education Benefit Program
Ch. 33 Entitlement Percentage: %
Ch. 35 Ch. 1606 Ch. 1607 Ch. 31 Ch. 30
(Dependent) (Reservist) (Deployed Reservist) (Voc. Rehab) (Active duty)
Remaining Entitlement (days/months of remaining benefit):
Have you established an eBenefits account at https://www.ebenefits.va.gov/ebenefits-portal/ebenefits.portal?
Yes If no, it is recommended that you create an eBenefits account.
What is your relationship to the veteran who is entitled to the education benefit? (i.e. “self”, “spouse”, “child”)
I certify that all courses are applicable to my degree program and meet VA requirements. I agree to notify the school and VA of any
changes in my credit hours within 10 days. I understand the completion of this BC3 form assures me of enrollment certification with
the Department of Veterans Affairs, but does not guarantee payment from the VA. Payment depends upon my enrollment in an
approved program, my not owing money to the VA for any overpayments and my compliance with all other VA regulations. I further
understand that any information on this form may be shared with the VA at its request.
Student Signature: Date:
Questions or Concerns? Contact: Stella Smith 724.287.8711 ext. 8335 firstname.lastname@example.org
Certification will not occur until you are registered for classes and this form is completed and returned to
the Financial Aid Office P.O. Box 1203 Butler, PA 16003-1203
Fax: 724.287.4961 Email: email@example.com
This form must be submitted for each term you wish to receive VA Education Benefits- No Exceptions
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