OFFICE OF VETERANS AFFAIRS
VA ENROLLMENT CERTIFICATION
REQUEST FORM
Important: Do not complete this form until you have finalized your schedule.
Please complete the following information:
Semester:
o
Fall
o
Spring
o
Summer 20
Have you applied for Financial Aid?
o
Yes
o
No
Have you applied for Federal Tuition Assistance?
o
Yes
o
No
Name
Student ID #
Phone Number
Email Address
Mailing Address
City, State, Zip Code
VA Chapter (Select One):
o
30 (MGIB)
o
1606 (Guard/Reserve)
o
31 (Voc Rehab)
o
35 (Dependent)
o
33 (Post 9/11 GI Bill)
Please check one or more options that apply to you:
o
Veteran
o
Transfer (Child)
o
Transfer (Spouse)
If spouse, is the service member on Active Duty?
o
Yes
o
No
It is yo
ur responsibility to run a Program Evaluation through your MyMTC account before and after registering to ensure each enrolled course fits
into your program of study. The VA Office will not certify classes that do not fit into your program of study
(unapplied coursework), which
could lead to a reduction in enrollment status and monthly benefits.
I further certify that I am legally liable for any overpayments of benefits resulting from failure to notify the office of changes in my
enrollment.
Student Signature Date
Term
(Ex. 1, 2, 5, 6, 7, W)
Add/Drop
Course
(Ex. ENG, MAT)
Number
(Ex. 101)
Section
(Ex. A01, B61)
Credit Repeat LDOA Grade
OFFICE USE ONLY:
Program'' Dual'Majo r'(Y/N)'' Hrs.'' ' Status'' Paid/PERC ' '
(FA,.CAP,'TA,''DEF,'Free'Tuition*'and'PD' Initials:''' '
*Free'Tuitio n'–'Enter'on'Aide'Sc r een: '' Amount:'' Initials:''' '
MIDLANDSTECH.EDU | PO Box 2408 | Columbia, SC 29202 | 803.738.7615
SD-19-5256Z-02-19
click to sign
signature
click to edit
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