Application for Certification of VA Education Benefits
Purpose: Used by students who desire to use Federal Veterans Education Benefits for the term indicated.
Summer
Student Instructions:
1. Register for courses in CheckMarq, complete one form for each term.
2. Complete Sections 1, 2 & 3 of this form using a computer.
a. a handwritten form will not be accepted.
b. an incomplete form will not be processed and will be returned to you for completion.
3. Print the form using the 'Print Form' button.
4. Sign the form in Section 4; a digital signature is not acceptable.
5. Submit the completed form via one of the methods listed at the bottom of this form.
NOTE: You must be registered for courses before enrollment can be reported to the VA. In order to ensure that you receive the appropriate benefit, it is your responsibility to inform
the School Certifying Official if you modify your enrollment after submitting this form. You are responsible for any debt assessed due to a change in your enrollment status.
MU Email Address
SSN
MUID
Phone
Major
Did you change your College or Major?
NOTE: if yes, you must complete a VA Form 22-1995 and attach it to this form
Yes No
VA File Number
(Chapter 35 claimants ONLY)
Year
@marquette.edu
Section 1: Student Information
Year
Spring
Year
Fall
Term for which you desire to use your benefit (check one)
NOTE: You must be registered for courses.
Section 2: Term Information
Degree Plan
(BA, BS, MA, MS, Ph.D., etc.)
Page 1 of 2
Rev. 10/2018
Hand Deliver: Marquette Central, Zilber Hall, 121, 1250 West Wisconsin Avenue, Milwaukee, WI 53233
Mail: Marquette University, Zilber Hall, 221, P.O. Box 1881, Milwaukee, WI 53201-1881
Email: otrdocs@marquette.edu
Name
Last name, First name Middle name
Address
street, city, state, zip code
The VA will use this address for all correspondence or payments not issued by EFT
Year
J-Session
NoYes
Are you enrolled in a Distance Learning (online) course(s) this term?
No
if no proceed to Section 3
Yes
if yes, work with your college/school and enter
location, full address and zip code below for each
course not meeting on Marquette's main campus
Are you enrolled in any course(s) not meeting on Marquette's main campus?
e.g. practicum, clinical, student teaching, internship
NoYes
Are you repeating a course(s) this term?
Location
Full address
zip code
zip code
Full address
Location
zip code
Full address
Location
zip code
Full address
Location
zip code
zip code
zip code
Full address
Full address
Full address
Location
Location
Location
Subject & Course Number
Subject & Course Number
Subject & Course Number
Subject & Course Number
Subject & Course Number
Subject & Course Number
Subject & Course Number
