ENROLLMENT DATA SHEET FOR VETERAN, MILITARY AND DEPENDENT STUDENTS
NAME_______________________________ SCHOOL ID _____________ SS# ______________ PHONE NO. ___________
MAILING ADDRESS FOR YOUR CHECK: ___________________________________________________________________
Street City State/Zip Code
DEGREE: ___________________ MAJOR: _________________________________ MINOR: ________________________
(Indicate if changed since last enrolled term)
Check the Benefit you are eligible to receive:
___Chapter 30 ___Chapter 31 ___Chapter 33 ___Chapter 35 ___Chapter 1606 ___Chapter 1607
(Service Beginning After 6/30/85) (Vocational Rehabilitation) (Post 911) (Dependent) (Reserve/National Guard)
TERMS OF ENROLLMENT FOR WHICH YOU ARE REQUESTING ENROLLMENT CERTIFICATION:
__FALL 20__ / __WINTER SESS 20__ / __SPRING 20__ / __5 WK SESSION 20__ / __5 WK SESSION 20__ / OTHER _________
PLEASE LIST COURSES FOR TERM(S) CHECKED ABOVE:
Dept/Crse No/Sec. No. Sem. Hours Dept/Crse No/Sec. No. Sem. Hours Dept/Crse No/Sec. No. Sem. Hours
_______________________ _______________________ _______________________
_______________________ _______________________ _______________________
_______________________ _______________________ _______________________
_______________________ _______________________ _______________________
_______________________ _______________________ _______________________
_______________________ _______________________ _______________________
_______________________ _______________________ _______________________
_______________________ _______________________ _______________________
_______________________ _______________________ _______________________
ARE THESE COURSES REQUIRED FOR YOUR DEGREE PROGRAM? ______
ARE YOU PLANNING TO ENROLL NEXT SEMESTER? _____
ARE THE COURSES LISTED ABOVE COURSES WHICH YOU ARE REPEATING? _____
IF YES, WHICH COURSES(S): ___________________________________________________________________________________
ARE YOU PLANNING TO GRADUATE AT THE END OF THIS SEMESTER? _____
PEASE READ THE FOLLOWING BEFORE SIGNING:
Undergraduates: You must be registered for 12 hours of coursework each semester in order to receive full-time benefits.
Remember that the VA will only pay for the minimum number of courses needed to complete your degree.
These courses must be specified in your program of study. Most internships and Independent Study courses are not eligible for
payment of benefits.
If at any time during the enrollment periods indicated above, I drop a course, withdraw from school, stop attending classes,
change my program/major, or change my status in any way that would affect VA benefits, I will notify the Veteran’s Office. I
understand that failure to notify this office of such changes could result in severe legal and financial penalties.
NOTE: Your signature below indicates that you fully understand this information and you agree to the conditions.
SIGNATURE: ___________________________________________________________ DATE: ______________________________
ANTICIPATED GRADUATION DATE: _________________________________________________________________
Please provide your SCHOOL E-MAIL _______________________________
***ECSU requires all students who are enrolled for at-least half–time enrollment status (6 or more credit hours) to have health
insurance. However, VA is not responsible for health insurance coverage.
RETURN FORM TO: (e-mail) veteran@ecsu.edu (fax) 252.335.3541; or drop-off - Wilhelmina Godfrey, Veterans Resource and
Information Center, 112 Ridley Student Center, Elizabeth City State University
