Admissions and Records *3000 Mission College Blvd Santa Clara CA 95054
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ENROLLMENT CERTIFICATION REQUEST FORM
Student Information
Student Name
Contact Information
Certification Information
I request Certification of Enrollment to be reported to Dept. of Veterans for:_______(units)
For the School Year & Term: Year:__________ □ Winter □ Spring □ Summer □ Fall
Current Objectives: □ AA Degree □ AS Degree □ Certificate
Major:________________________________ Transfer to (if applicable):_________________________________
Concurrent Enrollment: □ NO □ Yes Name of College/University:_____________________________
Last Term of attendance at MC:______________ Did you receive VA ED Benefits? □No □Yes
Advance Payment: □ No □ Yes (Must be requested at least 30 days before the start of the semester)
Reminder: VA student with (Chapter 30, 1606, 35, VRAP) must contact the VA monthly for verification of attendance
1-888-442-4551
I assume responsibility for notifying the VCO (Veteran Certifying Official) of any changes to my enrollment status. I hereby
acknowledge and understand the information provided by the VCO in regards to requirement/s mandated by the Department of
Veterans Affairs for VA Education Benefits and college policies as discussed by VCO and available for review from Mission College
Catalog. Any questions/ inquiries related to my VA Education Benefits must be directed to the Dept. of Veterans Affairs. Mission
College VCO will report enrollment and academic status but does not determine VA Education Benefit Eligibility.
Student Signature:__________________________________________________Date:_____________
________________________________
VA Certifying Official
Date:____________________________
Chapter Code:____________________
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signature
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