This form must be completed before each enrollment period (fall, spring, summer).
Name: SSN (Last 4): Student ID:
Telephone #: Address:
City: State: Zip:
Term: Year: Major:
Please Select One of the Chapters listed below:
CH 1606 (NG/Reservist) CH 1607 (REAP) CH 30
(Voc. Rehab.)
(Post 9/11)
(Dependents)
**VA File Number
Tuition Assistance Top-Up
Required:
(CH 30 and CH 33 Only)
Yes
No
Currently Active Duty: Yes No
Yes No
Please Select the Military Branch:
1. To qualify for FULL benefits, you must be a FULL-TIME student at EVERY point in the semester.
2. If you've changed your major, you have to complete a form before you can be certified.
3. If you owe a balance, your enrollment cannot be certified until it is paid-in-full.
4. CH 33 and CH 31 Students: If you receive any tuition-specific financial aid, it will impact your benefits.
5. The VA will only pay for classes that apply to your degree requirements.
I've read and understand the above statements. I also understand that all communication will be done via my USM EMAIL ACCOUNT and I
must notify the VA certifying official of any changes to my enrollment after I have submitted this form.
Signature of Student Date
The information below must be completed by your Advisor or your department representative. **CH33 students enrolled in
Internships/Externships/Co-Ops/Practicum/Student Teaching/Study Abroad, should list the zip code of location next to the
corresponding class listed below and provide a copy of your placement**
(see example)
Course Description
Code
I verify that the courses listed above for the current enrollment period apply toward the student's degree requirements.
Signature of Advisor or Department Head
*Courses can be REQUIRED ELECTIVES
Date
