Veteran Services Intake Form
Last Name:
First Name:
Street Address:
City, State ZIP:
Primary Email:
Phone Number:
What is your major?
When do you
plan to begin
Check one:
What type of
degree are you
Check one:
AA Associate in Arts
(Transfer for higher degree)
AAS Associate in Applied Science
(Two-year Technical Degree)
Career or Technical Certificate
Which campus?
Poplarville Forrest County Hancock Center
Academic History
Have you ever attended PRCC before?
List any previous college(s) that you have attended, beginning with the most recent:
Name of School
City and State
Last Date Attended
Name of School
City and State
Last Date Attended
Name of School
City and State
Last Date Attended
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Pearl River Community College offers equal education and employment opportunities. The College does not discriminate on the basis of race, religion, color, sex, sexual
orientation, gender identity, age, national origin, veteran status, or disability. For inquiries regarding the non-discrimination policies or to request accommodations,
special assistance, or alternate format publication please contact Tonia Moody Seal, Director of Admissions and Records, and ADA/Civil Rights Coordinator, at P.O.
Box 5537, Poplarville, MS 39470 or 601-403-1060. For inquiries regarding Title IX, contact Maghan James, Assistant Vice President of Student Services and Title IX
Coordinator, P.O. Box 5560, Poplarville, MS 39470 or 601-403-1253.
VA Education Benefits Information
Have you used VA Education Benefits before?
Yes. Where?
Which VA
Benefit do you
plan to use at
Check one:
Chapter 30 Montgomery GI Bill
Chapter 31 Vocational Rehabilitation
Chapter 33 Post 9/11
Chapter 35 DEA Dependents’ Educational Assistance
Chapter 1606 Montgomery GI Bill Selected Reserves or National Guard
Chapter 1607 REAP Activated Reserves or Nat’l Guard under Title 10 Contingency Operations
Required Field for Chapter 35 ONLY:
VA File Number:__________________________
Are you a
Veteran or
Yes, my branch of Service is/was:
No, I am a:
Check all that apply:
Air Force
Coast Guard
National Guard/Reserves
Are you currently active duty?
Yes No
If yes, what is your scheduled separation date?
Read and initial each item:
It is my responsibility to complete a "Request for VA Certification" form for every semester that I wish
to use my VA Education Benefits at PRCC.
The VA will only pay for classes that pertain to my designated degree, and if I wish to change my major,
I will notify the VA Certifying Official before I do so.
Certification cannot be completed on Remedial or Developmental Courses taken online.
It is my responsibility to make sure that my balance is paid in full every semester.
If I change my schedule - withdraw, add, drop, etc. - I must contact the VA Certifying Official
immediately. Failure to do so may result in an overpayment that I may be responsible for paying back.
By signing this form, I attest that I have read and understand the statements above. I also understand that
all communication will be made via my PRCC Student Email account.
Student’s Signature
click to sign
click to edit