Cosumnes River College Veterans Services Office
8401 Center Parkway, Sacramento, CA 95823-5704 916-691-7422/Fax: 916-691-7467
VETERANS AND DEPENDENTS ENROLLMENT STATUS FORM
Instructions:
All veterans or dependents currently using their benefits need to file this form at the end of every semester to ensure that
they are certified for the following semester or session. CRC does not automatically certify future enrollments to keep your
benefits coming. That is your responsibility. Failure to follow these instructions will result in a delay of benefit payments. If you
are not a “continuing” CRC veteran, do not file this form. Instead, make an appointment with the VA certifying official.
Please allow 30 days for processing of your certification.
Name
Last First MI
Student ID Number
Mailing Address Fall Spring Summer Year
Email
Phone Home
Work
Cell
ENROLLMENT STATUS THIS SEMESTER:
□ Enrolled at CRC only
□ Concurrently enrolled at other college(s)
List colleges attending this semester (other than CRC)
□ I have a current VA Educational Program Planner on file Yes No
□ Chapter 33 only; will you receive the BOG fee waiver? Yes No
VETERAN/DEPENDENT CHAPTER: □ 30 □ 31 □ 33 □ 35 □ 1606 □ 1607 □ VRAP
CLASS SCHEDULE:
Class Name and Code Number (i.e. POLS 300) Units Class Name and Code Number (i.e. POLS 300) Units
Total Units Registered for Benefits
I understand that I must notify the VA certifying official IMMEDIATELY whenever I add or drop a class or repeat a class for which I have
received credit already. I acknowledge that these courses are outlined on my VA Educational Program Planner as classes needed to meet
requirements for my goal. I authorize the personnel in the CRC Veterans Services Office to provide to and receive information from the
Department of Veteran Affairs regarding my program.
Signature _ Date
STAFF USE ONLY:
□
DND indicator placed on record
□
PS entry
□
Tuition & Fees:
_____________.________
Received By:_______ Date:____/____/____ Processed By:_______ Date: ____/____/____
_09/12
Once the forms are completed, students may send from their Los Rios email account to: YangJ@crc.losrios.edu for processing.
