ENROLLMENT CERTIFICATION REQUEST FORM
COMPLETE THIS FORM IF YOU WILL BE USING ANY VA EDUCATION BENEFITS
Submit the signed and completed form by mail or in-person to:
Veterans Resource Center 25555 Hesperian BLVD, Hayward, CA 94545
Email: cc-veterans@chabotcollege.edu
Name: Student ID: SSN:
Address: City: State: Zip:
Email (all correspondence will be sent here) Phone:
Term to be certified (SELECT ONE):
Spring Year: _________
Fall
Summer
Degree Objective (SELECT ONE):
AA / AS
AA-T / AS-T
Certificate
Major/Program of Study: _______________________________
VA Education Benefits (SELECT ONE):
Chapter 30: Montgomery GI Bill
Chapter 31: Vocational Rehabilitation
Voc. Rehab Counselor: ______________________
Chapter 33: Post 9/11 GI Bill: ______%
Chapter 33 TOE: Post 9/11 GI Bill (Dependent): ______%
Chapter 35: Dependents Education Assistance
Veteran’s Name: ______________________________
SSN:______________________ Suffix (A, B, C, D, E)_______
Chapter 1606: Selected Reserve Montgomery GI Bill
Chapter 1607: Selected Reserve Montgomery GI Bill
Parent Letter School Name: _________________________________
SCO Contact Information: __________________________________
Term: ____________
Proof of Enrollment: Yes No
Courses
Registered
Units Start Date End Date
OFFICE
USE
Courses
Dropped/Withdrawn
Units Date Dropped
Total Units: Total Units:
STUDENT OBLIGATIONS Please read carefully and initial.
I understand that:
_____ I must submit an Enrollment Certification Request form each term I wish to use my VA education benefits.
_____ I am required to have a current Veteran Ed-Plan on file with Chabot's Veterans Resource Center before any courses can be certified
_____ I can only receive benefits for courses required and outlined on my Veterans Ed-Plan and I must maintain good academic standing.
_____ I am required to have any and all official transcripts submitted to the Admissions & Records Office by the end of my second semester.
_____ I am required to submit the "Incoming Transcript/AP Test Evaluation" form along with my Official Transcripts to Admissions & Records.
_____ I am required to notify the Veterans Resource Center at Chabot of any/all changes to my class registration during the term.
_____ Changes in enrollment (withdraws, W grade and drops) may result in student debt or overpayment.
_____ Non-standard term (14 weeks or less) may affect my basic housing allowance and may be paid at a different rate as determined by the VA.
_____ My Rate of Pursuit (ROP) must be 100% in order to receive the maximum benefit payable.
_____ I am not repeating any course I have previously received credit for and all information provided is current and correct.
_____ FOR STUDENTS RECEIVING CHAPTER 30, 1606, 1607 BENEFITS: I understand that I am required to verify enrollment at the end of each
month. Failure to do so will result in an interruption of my benefits. (Verification of Enrollment: 1-877-823-2378 or https:www.gibill.va.gov/wave)
_____ FOR STUDENTS RECEIVING CHAPTER 33 (POST 9/11) BENEFITS: I understand that I will not receive any monthly allowance if I my ROP
is less than 51%. A pro-rated amount will be determined by the VA when my ROP is less than 100%. I understand that if enrolled in solely
online courses, my BAH will be half the national average for an E-5 with dependents ($894.50 for 19/20).
SIGNATURE: _______________________________________________ Date:___________________
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