In consideration of my enrollment at Dyersburg State Community
College in a program of education for which I may be entitled to
receive veterans benefits, and certification by Dyersburg State
Community College to the Department of Veterans Affairs of my
initial enrollment, and subsequent continued enrollment in
qualified courses leading toward my designated educational
objective, I hereby agree to comply with, and accept
responsibility for compliance with all laws and regulations
controlling eligibility for and receipt of veterans benefits by
veterans and other eligible persons, and I further agree to
indemnify and hold harmless Dyersburg State Community College
against any liability of my failure to comply with all laws and
regulations concerning eligibility for and receipt of veterans
benefits, and to pay to Dyersburg State Community College all
costs of collection, including reasonable attorney’s fees, which
are incurred in the recovery from me of any funds received from
the Department of Veterans Affairs which I was not entitled to
receive under said laws and regulations.
Pursuant to the foregoing, I hereby acknowledge and agree that it
is my responsibility to notify the Dyersburg State Community
College Office of Veterans Affairs immediately if I drop or
withdraw from any course or courses for which I have been
certified as enrolled by Dyersburg State Community College, and
to return to the Veterans Administration any funds I received for
enrollment in courses which I have dropped or from which I have
withdrawn, or for which I am not otherwise entitled to receive
such payments. I further acknowledge and agree that I am not
entitled to receive benefits for enrollment in courses which I
have previously taken and received other than a failing grade, or
for enrollment in courses which do not advance my credit hour
progress toward my specific educational objective--e.g. elective
courses in excess of the maximum electives allowed.
I further acknowledge my responsibility to maintain proper
attendance and satisfactory progress toward completion of all
courses for which I enroll at Dyersburg State Community College
and to notify the Department of Veterans Affairs or the
certifying official at this school immediately of my
discontinuance of enrollment in any course and of any changes or
conditions affecting my entitlement of benefits.
This __________ day of __________________________, 20_____
I have selected the following program of study which will lead to
an Associate Degree, Associate of Applied Science Degree, or
Certificate (be specific as stated in the General Catalog):
Program of Study: __________________________________
I hereby certify that I have read and fully understand the
certification requirements for receipt of veterans’ benefits and
accept full responsibility for fulfilling all requirements. I
have also received the following:
Summary of Educational Benefits pamphlet ____________
A copy of CERTIFICATION INFORMATION ______________
Signed: __________________________________________
Date: _____________________________
(This form must be completed and returned to the VA Office at
Dyersburg State Community College. Certification for VA benefits
will not be submitted by the College until the completed form is
on file.)