Please submit a Certificate of Eligibility and DD214 together with this signed application
to your
school's certifying official, located in the Registrar's Office.
This form
must be completed for each term you wish to receive benefits.
NOTE: Do not use this form if you receive VA Vocational Rehabilitation benefits, Chapter 31, in which case you must
work with your VA Rehabilitation Counselor and submit direct payment certification request s to
the Registrar 's Office.
Student Name: __________________ _
Student ID#: _________________ _
Degree: _____________________ _
Program of Study: _______________ _
Term: D ummer
Number of credits enrolling for term indicated ___ _
(check one)
Admit Term: ___________________ _
Expected Graduation Date: ____________ _
Address: _______________________________________________ _
Education Benefit Chapter (check one):
30 (Montgomery GI Bill)
1606 (Selected Reserv e)
1607 (REAP)
35 (Dependent Educational Assistance)
33 (Post 9/11 GI Bill)
40% 50% 60% 70¾ 80% 90¾ 100%
*100% category processed as Yellow Ribbon, per eligibility criteria
Status (check all that apply):
0 Active Duty D Veteran
D Dependent (DEA)
Transfer Entitlement (spouse)
Transfer Entitlement (child)
Nation al Guard - which state? _____ _
If Active Duty, will you be using TA? Y / N
If yes, what amount? $
Did you file a FAFSA this year? Y / N
My signature below indicaces thac I undemand that in order to comply with Veteran 's Administration regulations, Touro College and Universiry must submit
registration and academic progress reports to the Veteran 's Administr ,uion .
Furthermore, I must report any changes in my registration status (listed below)
two weeks from the date of their occurrence. I also understand that registracion changes may affect rhe VA Benefit amounts paid to me. A change in my
registration can cause overpayment on my VA accow1t, which
I would be required to repay.
Registration changes that must be reported:
Classes Report the day the add becomes effective
Dropped ClassesReport the last day of attendance in the class
Audit Grades Report trus grade option, ifl choose it. The VA will not pay for classes for which I request an audit grade .
Withdrawals Report the last day of attendance
Repeated Classes Report any classI am repeating for credit. The VA will pay for such a class only if the initial grade was an "'F ."
NA or Missing Grade A class with an "NA" (Never Attended) grade or missing grade will noc be paid by the VA l will be responsible to repay any monies received
for these classes.
I have read and understand the above statements and agree to comply .
Email Address (please print)