Student Name: ____________________________________ Student ID: _____
Address: _____________________________________________________________________________
Phone: _______________________________________ Email Address: ________________________________
Major: __________________________________________
SPECIFY CHAPTER FOR CERTIFICATION:
( ) Chapter 33 - Post 911/GI Bill (prior active duty after 9/11/01)
( ) Chapter 30 - Montgomery GI Bill (prior active duty)
( ) Chapter 1606 - Montgomery GI Bill (Reserves/National Guard) Chapter 1606 and Tuition Assistance cannot be used
at the same time.
( ) Chapter 31 Vocational Rehabilitation
( ) Chapter 35 Survivors' and Dependents' Educational Assistance Program (DEA)
I acknowledge that I have met with my faculty advisor and I am registered for only courses that are required for
my program.
I understand LRCC policy on satisfactory progress and LRCC procedures for adding, dropping and withdrawal from
school. I agree that it is my responsibility to comply with these policies and procedures.
I accept personal liability for any overpayment made to me by the VA which results from my failure to comply
with LRCC policies and procedures, or VA regulations, and agree to refund such overpayment promptly to the VA
or LRCC.
I will notify the Registrar’s Office if I do not wish to be certified for a semester.
I agree that if I withdraw from my classes or leave LRCC, for any reason, I will notify IN WRITING OR EMAIL the
LRCC Certifying Official in the Registrar’s Office. (this includes graduation)
I agree to promptly notify IN WRITING OR EMAIL the LRCC Certifying Official of ANY and ALL changes which
occur in the information furnished in this form.
I authorize the information furnished on this form to be released to the VA, National Guard, or funding agency. I
authorize LRCC to submit to the VA, any changes that may occur which affect my benefit payments and to share
academic information as requested by the VA on my behalf. I further agree that LRCC may share my information
with the VA, National Guard, or funding agency to include: Social Security number, address, grades, academic
information and rate of academic progress. I understand if I do not want to be certified, I must notify the
Registrar’s Office. By signing this document, I have read, understand, and agree to the terms.
Signature: ________________________________________________ Date: _____________________
10/25/2019
VA Certification Request From
Office of the Registrar
379 Belmont Road, Laconia, NH 03246
Phone: (603) 524-3207 Fax: (603) 524-8084
Email: lrccregistrar@ccsnh.edu
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