BPCC VA EDUCATION ENROLLMENT FORM
Chapter
SELECT ONE FROM THE FOLLOWING
__
_
_New - At BPCC- Is
this your first time at BPCC using Benefits?
____Continuing -Enrolled at BPCC in the past three years using benefits
____Visiting - Attending BPCC while pursuing degree at another school
(Written approval is required from your Parent School for BPCC classes)
LoLA #______________________
SEMESTER
______Fall ______Winter ______Spring ______Summer
Year: 20_____
Check One Below
Active Duty_____
Active Duty Spouse_____ Active Duty Child_____
Veteran ______
Veteran
Spouse______Veteran Child______
Louisiana National Guard_______ Reserves ______
STUDENT INFORMATION
NAME ________________________________Veteran’s SSN _____- ____ - _______(___)
ADDRESS______________________________ Student’s SSN ______
-____ -_______
CITY/STATE/ZIP _____________________________
Home Phone________________Work Phone_____________Cell
Phone______________
Email Address_________________________________
SCO Notes
__________________
__________________
__________________
__________________
STUDENT RESPONSIBILITIES
1)Notify the School Certifying Official when education benefits have expired and when
a class is added or dropped.
2)Book vouchers are only issued to students using Chapter 31 Vocational Rehabilitation
benefits.
3) A GPA below a 2.0 may affect your education benefits, waivers, or exemptions.
By signing this VA Enrollment form, I understand that it is my responsibility to ensure
my classes listed on the back of this form are part of my current program that I am
pursuing at BPCC. Any classes I take outside of my specified program may cause a debt
to me by the VA.
Student’s Signature_____________________________Date__________________
click to sign
signature
click to edit
PLEASE CHECK ONE OR MORE OF THE BENEFITS YOU ARE USING
DEVELOPMENTAL COURSEWORK MUST BE TAKEN ON THE PHYSICAL CAMPUS
ADVISOR COMMENTS
_____________________________________________________________________________________
_____________________________________________________________________________________
The classes listed above are required for completion of the student’s program of study as specified in the
current academic catalog for BPCC, to the best of my knowledge.
Academic Advisor’s Signature ______________________________________ Date __________________
____ Chapter 30 Montgomery GI Bill
____ Chapter 31 VA Vocational Rehabilitation & Training
____ Chapter 33 The Post 9/11 GI Bill (Certificate of Eligibility required)
____ Chapter 35 DEA Dependent’s Education Assistance Program
____ Chapter 1606 Reserve GI Bill
____ Chapter 1607 REAP Reserve GI Bill
____ Check Here - If you receive LA VA Title 29 Tuition and Fee Exemption (Original Certificate Required)
____ Check Here - If you have the Louisiana National Guard Waiver
THINGS TO KNOW
**All classes below MUST be in your program of study
**Retaking courses for a better grade is prohibited when using the GI Bill
Degree of Study______________________________Concentration__________________________
COURSES TAKEN FOR TERM
Initials
DEVELOPMENTAL COURSES TAKEN (ON CAMPUS ONLY)
Bossier Parish Community College is accredited by the Southern Association of Colleges and Schools Commission on Colleges to award associate degrees,
diplomas, and certificates. Contact the Commission on Colleges at 1866 Southern Lane, Decatur, Georgia 30033-4097 or call 404-679-4500 for questions about
the accreditation of Bossier Parish Community College. • Bossier Parish Community College does not discriminate on the basis of race, color, national origin,
gender, age, religion, qualified disability, marital status, veteran's status, or sexual orientation in admission to its programs, services, or activities, in access to
them, in treatment of individuals, or in any aspect of its operations. Bossier Parish Community College does not discriminate in its hiring or employment
practices. • Coordinator for Section 504 and ADA: Angie Cao, Student and Disability Services Specialist - Disability Services, 6220 East Texas Street, Bossier City,
LA 71111 - (318) 678-6511 - acao@bpcc.edu - 8:00 a.m.–4:30 p.m. M-F, excluding holidays and weekends. • Equity/Compliance Coordinator: Teri Bashara,
Director of Human Resources - Human Resources Office, 6220 East Texas Street, Bossier City, LA 71111 - (318) 678-6056 - 8:00 a.m.–4:30 p.m. M-F, excluding
holidays and weekends.