The following information must be completed (please print) before your certification can be submitted to the Regional VA Office.
Consult with your Academic Advisor to verify your Schedule of Courses. Upon completion, submit this form, a copy of the
Certificate of Eligibility, 1905 or Exemption Certificate and a copy of your paid receipt to the Registrar’s Office for processing
each semester.
Year SEMESTER: Fall Spring Summer I Summer III
Name
Summer II
SUSLA Student ID#
Last First MI Maiden
Date of Birth Phone Number Major:
E-mail Address: @skymail.susla.edu
Personal E-mail Address: ____________________________________________
CHAPTER: Please check the appropriate box. 33/Post 911 (GI Bill) 31 (Vocational Rehabilitation)
30 (Montgomery GI Bill) 1606 (National Guard, Reserve or Navy) LA State Fee Exemption Certificate
35 (Spouse or Dependents) Veteran’s Social Security Number
Your Academic Advisor must verify that the courses you are enrolled in leads to an Associate Degree, Certificate or Technical
Diploma in the above mentioned program of study (major).
Advisor’s Name (please print) Signature Date
The completion of this form authorizes the Veteran’s School Certifying Official to certify my enrollment and provide academic record
information to the Department of Veterans Affairs.
It is my responsibility to notify the Veteran’s School Certifying Official if I add or drop any courses, withdraw from the
University, change my major, or have any other changes in my enrollment status or registration. I may do this in person or
through my student email to registraroffice@susla.edu.
I understand that SUSLA will process the VA Data Form, via “VA ONCE”,
after the official census date (14
th
class day for Fall and Spring/7
th
class day for
Summer) of each semester.
Student’s Signature Date
Yes
No
Is this your first time requesting VA Benefits at SUSLA? (If yes, the Certificate of Eligibility is required
Have you received VA Benefits at any other institution? If Yes, please list:
Are you currently on active duty?
Are you a visiting student?
Do you receive any of the following? Tuition Scholarship (i.e., TOPS), Tuition Exemption (i.e., National Guard)
Military Tuition Assistance
Have you ever declared Academic Bankruptcy or Amnesty?
Are you enrolled in classes at another institution this semester?
CRN
COURSE
PREFIX
COURSE
NUMBER
SECTION
NUMBER
CREDIT
HOURS
CLINICAL/TRAINING
SITE LOCATION
Registrar’s Office Use Only
Certification Date
Certification ID#
Processed by:
Records and Registration
VA Enrollment Certification Request Form
RO: VA Certification Request Form-Revised 07/14:07/15:07/16:10/18:08/19-LR
NOTE: An email address is required to
receive updates about your VA benefits.
Select One from the Dropdown Menu Below
click to sign
signature
click to edit
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