VETERANS REQUEST FOR CERTIFICATION
Veterans Center 2800 S Lone Tree Rd Flagstaff, AZ 86005-2701 PH: 928-226-4309 FAX: 928-226-4110 . cccvets@coconino.edu
VA-810 VA Request for Cert 20181205
I am a: New Student at CCC Returning Student to CCC
I am applying for: Fall 20 Spring 20 Summer 20
Chapter of Veterans Benefits I am applying for:
Chapter 30 Chapter 31 Chapter 33 (Post 9/11) Chapter 35- Claim #
1606 Guest Student at CCC- Parent School Name:
What is your degree or certificate program?
Are you changing your major from what it used to be? Yes No
List below ALL previously attended colleges, universities, trade/vocational schools, and military
transcripts. You are required to submit official transcripts from any schools you have attended. Failure to list
all previously attended colleges can result in a debt to the VA. Attach additional sheet if necessary.
Have you received a degree prior to attending CCC? Yes No
If so, please list the school and degree received:
Statement of Understanding: (Please initial each statement after reading it).
_____ I understand that it is my responsibility to submit all official transcripts from ALL previously attended
colleges, universities, trade/vocational schools, and military transcripts regardless of whether I received
Veteran's educational benefits there or not. VA educational benefits will not be certified until all
official transcripts are turned in and evaluated.
_____ I understand that it is my responsibility to report any changes in my schedule or degree.
_____ I understand that it is my responsibility for any overpayment made to me due to changes in my
schedule or degree.
_____ I understand that the Veterans Administration will not certify classes that do not count towards my
degree.
_____ I understand that I am ultimately responsible for payment of all tuition, books and fees, including any
“No show” and dropped class fees
_____ I understand I will be responsible for all tuition charges in excess of the In-State resident rate.
Signature Date
CCC ID# Last Name First Name MI
Mailing Address City ST Zip Code
Telephone No. (include area code) Email Address
