ENROLLMENT FORM
Last Name: ______________________________ First Name: _______________________________ MI: __________
VA File (Chapter 31&35 only):_____ _____________________ Social Security No: _____________________________
Mailing Address: ____________________________________________________________________________________
City: ___________________________________ State: _____________________ Zip: ___________________________
Home Telephone: ___________________________________ Cell Phone: _____________________________________
E-Mail Address: _____________________________________________________________________________________
__________________________________________________________________________________________________
When wi
ll you be using VA education benefits?
Year: ________________ Select one: Fall Spring Summer
Estimated credits _________
What level of degree will you be working towards? Bachelors Masters Not Degree Seeking
Academic Program/Major: _______________
Has t
his changed from last time you used benefits? _______ If yes, you must notify the VA (form 22-1995)
__________________________________________________________________________________________________
Please select the type of VA Educational Benefit you are receiving (below):
Chapter 30
Mon
tgomery GI Bill
Chapter 31
Vocational Rehab
Chapter 33
Post 9/11
Chapter 35
Dependents
Chapter 1606
Reservist GI Bill
Chapter 1607
Reservist GI Bill
1.
Have you applied for your benefits with the VA through VONAPP or by mail? Yes No
If yes, when? ____________
2.
Have you provided your Certificate of Eligibility to our office yet? Yes No
If yes, when? ______________
3. Have you used VA Education benefits at another school?
Yes No
a. If yes, you must notify the VA (form 22-1995)
4.
Are you active duty? Yes No
a. If yes, are you receiving Federal Tuition Assistance? Yes No
5.
Do you plan to graduate this semester? Yes No
__________________________________________________________________________________________________
Signature Required for Certification
By signing this form I understand and acknowledge the requirements of receiving VA Education Benefits
• I understand I need to apply to the VA and provide a Cert. Of Eligibility to the Office of Veterans Affairs
• I understand that I must notify the Office of Veterans Affairs of any adjustments to my schedule within 48 hours.
• I understand that I must submit this form every semester I wish to use VA education benefits.
• I understand that I must take courses that fulfill my degree requirements and if I change my program, I must
notify the VA (form 22-1995) and provide a copy of the notice to the Office of Veterans Affairs.
Signature: ________________________________________________________ Date: ______________________
Revised Edition 6/26/18 JD
Office of Veterans Affairs
1570 Baltimore Pike
Lincoln University, PA 19352
Phone: 484-365-7950 Fax: 484-365-7971
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