VA DATA FORM
Name SSN #___________________ CCC ID # __________
Address Date of Birth: ____/____/19___
City/State/Zip Phone: (_____) ________________________
E-MAIL:__________________________________________________________________________________
Veterans Only:
Branch of Service: ___________________________ Date of Separation: ______________________________
Honorable Discharge: Are you currently Active Duty?
Dependents Only:
Are you a dependant of a Veteran? If yes, Relationship:
Name of Veteran ___________________ SSN# or Claim#____________________
All Students:
Have you ever applied for any MGIB Educational Benefits?
Have you attended another college previously? When?
Where? _____________________________________________
Will CCC be your Primary School? (Where you will receive your Associates degree from?)
If Not; Which School is? _____________________________________
Degree or Certificate Choice
Degree/Program/Certificate:
For School Use Only:
Chapter: _________________________ CH31 Counselor:________________________________
Military Transcripts: Other College Transcripts:
Notes:____________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
Air Force
Yes
No
No
No
No
Yes
CH 33
Joint Services Transcript (JST)
CLACKAMAS COMMUNITY COLLEGE VETERAN SERVICES OFFICE
STATEMENT OF RIGHTS AND RESPONSIBILITIES
Name_____________________________________Chapter_____________________________
StudentID#_______________________________ Major______________________________
VA File # _________________________________
I understand and acknowledge that being a student in receipt of veterans’ educational benefits gives me some additional
responsibilities and duties while pursuing my educational objective. In particular:
____The MyClackamas email account is the primary method the college and the Veteran Services Office (VSO) will use for
communications and I will check it regularly and reply as requested and required.
____I will obtain official grade transcripts from all colleges and other postsecondary schools that I have attended. Official transcripts
must be received by the CCC Records Office prior to the end of my first term in attendance. Send transcripts to: Records Office,
Clackamas Community College, 19600 Molalla Ave, Oregon City, OR 97045
____I must submit a “Veterans Request for Certification” form to the VSO each term I intend to utilize VA benefits. In addition, I
must immediately report to the VSO any and all changes in my enrollment status and any changes to my declared degree.
____All classes I take must apply directly toward my declared degree objective. If I choose to take a class that does not apply to my
degree objective or if I drop a class for which the VA has provided educational benefits, I am solely responsible for any
overpayment amount to be repaid to the VA.
____I must consistently meet the CCC Standards for Satisfactory Academic Progress (SSAP) which includes maintaining a
cumulative minimum GPA of 2.0 and a course completion rate of 67% of all attempted courses per academic term. The full standards
can be found in the college catalog. Failure to meet the SSAP will result in a change of student status to Academic Alert, Academic
Probation, or Academic Suspension in accordance with College policy. If I am placed on Academic Suspension, my Veterans
Education benefits will also be suspended.
____I understand that Veterans Education Benefits will not pay for: self-paced classes, auditing classes, repeating classes which have
been successfully completed and classes in which I receive a final grade of: N, W, X, or Y. I understand that these grades may
result in an overpayment.
____I understand that the CCC Veteran Services Office (VSO) is an office of Clackamas Community College and not the Veterans
Administration.
____I understand that the VSO will retain records pertaining to my education and use of Veterans Education Benefits in paper and
electronic form in accordance with the regulations of the Veterans Administration. I authorize the staff of the VSO to use this
information, including but not limited to class registration, changes in enrollment and final grades, in the normal course of certifying
my eligibility for education benefits and as requested by authorized representatives of the Veterans Administration to ensure
compliance with applicable law and regulations. I am responsible for contacting the VA and/or the VSO with questions pertaining to
my file.
____Pay issues and questions should be directed to the VA at 1-888-442-4551 or via the VA e-benefits portal.
Signature_________________________________________________ Date_____________________________
Updated 14 November 2013
CCC Veteran Services “Getting Started” Check List
___Complete the Application for Admission to CCC at: http://www.clackamas.edu/Apply/.
___After applying to CCC you will receive a letter or email with your Student ID #, you then need to set up a
MyClackamas Account, at: www.clackamas.edu . This is how CCC communicates with its students.
___Review and Decide on what VA Education Benefit to use: http://www.gibill.va.gov/apply-for-
benefits/road-map/1-determine-your-best-benefit.html .
___Complete, submit, print, and sign your VA application at https://vabenefits.vba.va.gov/vonapp/main.asp
VA Form # 22 - _____.
___Take Placement Tests: Math, Reading, Writing and Computer Science. No appointment, no charge, tests
can be done in RR 140, or at the Harmony Campus.
___Declare a Degree or Certificate.
___Meet with an Academic Advisor in the Community Center and build a Veterans Educational Plan and
schedule participation in a NSA (New Student Advising) Seminar.
___Enroll in classes that apply to your declared degree. You can enroll through your MyClackamas account.
Open enrollment for the next term begins on ____________
___Complete a “Veterans Request for Certification form; this form is required each term you attend
___Complete your FAFSA (Optional) Go to: www.fafsa.ed.gov (CCC school code is 004878).
___Order transcripts from ALL sources military & other colleges/universities (these MUST arrive & be
evaluated within ONE term from your original admission.)
___Bring in your DD-214 (member 4 copy) and/or NOBE with you (Not required for Dependants).
___After completing the above steps, and the CCC Veterans Services in-house paperwork, set an appointment
with a Veterans Benefits Specialist to have your file reviewed, and your courses certified with the VA.
For questions or to schedule an appointment, email or call:
VA Work Study
Students
503-594-6609
Vet Info
503-594-3438
vetinfo@clackamas.edu
CLACKAMAS COMMUNITY COLLEGE VETERAN SERVICES OFFICE
IMPORTANT PHONE NUMBERS & WEB RESOURCES
CCC VETERAN SERVICES OFFICE:
C
CC Oregon City Campus Phone: (503) 594-3438
Community Center 100 FAX: (503) 650-6654
19600 Molalla Ave. vetinfo@clackamas.edu
Oregon City, OR 97045 http://www.clackamas.edu/Veterans/
https://www.facebook.com/cccvetcenter
CCC Veteran Certifying Officials:
(503) 594-3442 gregm@clackamas.edu
RB Green
Eboni Frederick-Pettway (503) 594-3422 ebonifp@clackamas.edu
w
ww.gibill.va.gov
VA Regional Office: 1-888-442-4551;
For questions on VA education benefits and payments
h
ttps://www.gibill.va.gov/wave/default.cfm
Verification of Enrollment: 1-877-823-2378;
Chapters 30, 1606, 1607, and VRAP Call or go online to verify your enrollment on the last day of each month of
attendance
D
irect Deposit:
1-877-838-2778
To start, stop, or change your direct deposit information
V
A Debt Management Center:
1-800-827-0648
V
A Vocational Rehabilitation Office:
503-412-4577
www
.va.gov
Veterans Administration: 1-800-827-1000;
For information on benefits available to Veterans
www.archives.gov/veterans/evetrecsDD-214: Copies can be obtained at
www.goarmyed.com; 1-800-817-9990 Oregon Army National Guard Tuition Assistance:
www.orng-vet.org Oregon National Guard Post Deployment Assistance: 1-888-688-2264 or 503-584-2391
VA Hospital Portland: 503-220-8262 Portland Vet Center: 503-273-5370
Transcripts:
Army, Navy/Marine Corps, and Coast Guard Transcripts: https://jst.doded.mil/
Air Force Transcripts: (CCAF) www.au.af.mil/au/ccaf
Send all Transcripts to:
Clackamas Community College Records Office
19600 Molalla Ave
Oregon City, OR 97045
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