Fillable Veterans Certification Requestand Statementof Obligation2019 (Las Positas College)

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Veterans Certification Requestand Statementof Obligation2019 (Las Positas College)

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VA EDUCATION BENEFITS CERTIFICATION REQUEST
and STATEMENT OF OBLIGATION
Part I: Student Information – Please Print
New/First Time at LPC *Must provide DD214 & COE Continuing Student
First N
ame:_______________________________________ Last Name:_______________________________________________
Student ID:
W______________________ SSN:________________________
Current Address:______________________________________________ City:_____________________ CA Zip:__________
Phone Number:_________________________
Chapter: 31 33 33 TOE 35 Montgomery GI 1606
Note: If CH 35: Name of Parent/Spouse:__________________________________ SSN:_____________________________
**Must provide a copy of student birth if dependent or marriage certificate if spouse . (Office Use Only: Date Recd:________ By:_______ )
Major or Certificate:
AA or AA-T AS or AS-T Transfer Program Certificate
Major:____________________________________________________________________________
College Transcripts &
Date Official Transcripts were received:
Institution
Date Official
Transcripts Recd
Institution
Date Official
Transcripts Recd
1.
3.
2.
4.
Part II: Registration Information
Ter
m:
Fall Spring Summer Year:______
CRN
Course Title
Units
O=Online/Hybrid
or R= Onsite
Start
Date
End
Date
Office Use Only – Notate Adding or
Dropping courses & Date
TOTAL UNITS:
Ter
m:
Fall Spring Summer Year:______
CRN
Course Title
Units
O=Online/Hybrid
or R= Onsite
Start
Date
End
Date
Office Use Only – Notate Adding or
Dropping courses & Date
TOTAL UNITS:
Ter
m:
Fall Spring Summer Year:______
CRN
Course Title
Units
O=Online/Hybrid
or R= Onsite
Start
Date
End
Date
Office Use Only – Notate Adding or
Dropping courses & Date
TOTAL UNITS:
VA EDUCATION BENEFITS CERTIFICATION REQUEST
and STATEMENT OF OBLIGATION
Part III: Student Agreements
Initial
I certify that:
I am legally enrolled in the above courses, I am not repeating any course for which I have previously received credit, and all
information provided is current and correct.
I understand that I am required to have an Education Plan written by a VA-approved counselor prior to my second semester.
I understand that I am required to inform the Las Positas Community College Veterans Resource Center of any and all changes to
my schedule during the semester. A failure to do so may result in an overpayment on my part, which would result in a debt with
the U.S. Department of Veterans Affairs.
I understand that I am required to have any and all official transcripts sent to Las Positas Community College, Admissions and
Records prior to my Education Plan. (Official copies must be submitted.)
Student Signature:___________________________________________________ Date:______________________
Part IV: Office Use Only
BOGGW: Yes Date:________ No Residency: Yes or No (Code:_____)
VA Once: Date Processed:________ Term:
Fall
Spring
Summer Year:______
VETERANS SPECIALIST LOG
Term
F/Sp/Su
Year
Date
Form
Submitted
VAOnce
Y/N
Notes:
Initials
✔
✔
✔
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Veterans Certification Requestand Statementof Obligation2019 (Las Positas College)

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Completed 18 July 2020

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