H.B. 269 Military Service Credit Agreement
The University of Texas at Tyler
Return form with student, advisor, and chair signatures to the Enrollment Service Center (ADM 230)
You may be entitled to know what information The University of Texas at Tyler collects concerning you. You may review and have UT Tyler correct this information according to procedures set forth in UT
Systems UTS 139. The law is found in sections 552.021, 552.023, and 559.004 of the Texas Government Code.
Received by: Processed by: Date: Revised: 02/2017
Printed Name: ______________________________________________________________________
(First) (Middle) (Last)
Signature/PIN: ________________________________________ Phone #: ___________________
Student ID Number: ______________________________ Date: _______________________
Major: __________________________________________
This form is to be used to claim credits authorized under H.B. 269 only. This document is not for use in the assessment of military
credits based on training / experience as documented on a Joint Services Transcript, ACE evaluation, or other sources (complete a
Military Service Credit Evaluation form), or for the review of hours from regionally accredited institutions such as the Community
College of the Air Force.
Certification of Understanding:
By completing this form and signing in the section provided below I hereby certify that:
I have read the Military Service Credit section of the Undergraduate Catalog
I meet all eligibility criteria for this program and have provided all necessary documentation
o DD 214/Disability Discharge Documentation on File
o Graduated from Accredited High School
o Documentation verifying a minimum of 2 years’ service
I have met with my Academic Advisor and understand that I am eligible to receive credit for all physical education
credits required for an undergraduate degree and up to 12 lower-division semester credit hours that may be applied to
satisfy any elective course requirements for my degree program for courses outside the major or minor.
I understand the credit hours awarded under this program are irrevocable once assigned and will apply toward any
programs including, but not limited to, Texas B-On-Time Loan forgiveness, the Tuition Rebate for Qualified Students,
and Excess Hours.
This Section to be Completed by Academic Advisor
□ The student named on this form has required physical education credits that are required as part of their degree plan.
Please award the following number of hours accordingly: ________
□ The student named on this form has been approved to satisfy not more than 12 elective credit hours using credit awarded
under this program. Please award the following number of hours accordingly, split between lower and upper-division as
indicated:
Lower-Division Credits: ________ Upper-Division Credits: ________
Student’s Signature/PIN: Date:
College Advisor’s Signature: Date:
Department Chair’s Signature: Date:
Registrar’s Signature: Date: