Request for VA Certification Semester/Term
Name SSN
Street Address City/State/ZIP
Student ID Number Phone Number
CHECK THE VA EDUCATIONAL BENEFIT YOU ARE CLAIMING
Chapter 30 (
Montgomery GI Bill) Chapter 31 (Vocational Rehabilitation) Chapter 33 (Post 9/11 GI Bill)
Chapter 35 (
Survivor/Dependent DEA) Chapter 1606 (Selected Reserve) Chapter 1607 (REAP)
CHECK YES OR NO TO THE FOLLOWING QUESTIONS
Yes No
Are you currently active duty military?
Are you concurrently enrolled at another school?
If Yes: Other school: Parent School: CCC Other
Degree/Major: Is this a new major? Yes No
Please INITIAL in the space provided after reading each of the following:
I must provide a copy of my VA Certificate of Eligibility to the VA School Certifying Official.
I must provide official transcripts from all colleges that I have previously attended to the Office of Admissions and Records.
I must have a major declared with Admissions and Records, if I change my major I must notify the VA School Certifying Official.
Only courses on my degree plan will be certified for VA benefits.
EACH TERM I must submit a CCC Request for VA Certification, signed by a CCC Academic Advisor, to the VA School Certifying
Official.
I must report any changes in my enrollment to the VA School Certifying Official and I acknowledge that I may be responsible for
charges that these changes incur.
I understand that I must make satisfactory academic progress toward graduation per the CCC Catalog in order to remain eligible
for VA benefits.
Unsatisfactory attendance on my part will be reported to VA and I will be responsible for any overpayments incurred.
If I am Chapter 30, 1606, 1607 or VRAP I must verify my continued enrollment at the end of each month at
http://www.gibill.va.gov/wave
I understand that all correspondence from the VA Certifying Official at CCC will be via my CCC student email.
By signing below, I affirm that I have read, understand, and will abide by the information above and that only classes listed on
this form will be certified for VA benefits.
Student Signature: Date:
Academic Advisor Signature: Date:
