Veterans Enrollment Certification Request Form
_________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Please fill out the form completely and return, along with a copy of your schedule to a Military & Veterans Office.
Name: ______________________________________________________
SSN: ______________________ VA File #: _____________________ Student ID #: __________________
(Last Four SSN for Returning Students) (Chapter 35 Students Only)
Address: _______________________________________________ City/State: _____________________________ Zip Code: ___________
Phone: Home: _________________________ Cell: _________________________ Email: _________________________________________
Current Degree Plan: _________________________________________________________________________________________________
ONLY LIST COURSES THAT CAN BE CERTIFIED BY VA
VA OFFICE USE ONLY
Course Prefix
(ENG)
Course #
(100)
Section #
(AC05)
# Credit Hours
(3)
TO
CREDIT
HOURS
TOTAL CREDITS ________ TOTAL CREDITS ____
STATEMENT OF UNDERSTANDING
1. EACH TERM I must report my registration and any changes in my enrollment to my campus Military & Veterans Services Office.
2. I have read, reviewed, and understand all the Federal Regulations and requirements pertaining to the VA Educational Chapter in which I have elected to
utilize. (www.gibill.va.gov)
3. I will not repeat any courses previously taken or completed except as permitted by VA regulation.
4. I understand that during certification for the current semester, classes that appear as open electives on your degree audit report and / or repeated
courses not permitted by VA regulation, will not be certified as hours toward VA stipend benefit and you will be responsible for the tuition and fees of
these courses if applicable.
5. I understand that courses scheduled to meet for other than the normal 16-week term are paid at a different housing allowance rate based on the number
of credits and length of course. See your campus office for details on irregular enrollment training time. (Chapter 31 & Chapter 33 Only)
6. I understand that not complying with all Veterans Services office policies, document request, and deadlines. Untimely submissions or inaccurate,
misleading or incomplete information will result in delays or discontinuation of my benefits and may result in overpayment.
7. I understand that it may take the VA up to 8 weeks to process my education benefits and CCAC up to 4 weeks to process your benefits, once funds
have been received from the VA.
8. I assume full responsibility for any debts owed to CCAC or the VA should I withdraw, drop, and over-payment occurs as a result of this certification, or
the VA revoking funding due to academic suspension.
Signature: __________________________________________________________________ Date: _______________________________
Changes in enrollment WILL AFFECT your benefits. Consult with the office BEFORE making any changes.
VA OFFICE USE ONLY: (Check off when completed; place date next to PERC & In-County Rate)
VETS XSTY PERC __________ In-County Rate ____________ VAOnce BIO
NOTES:
CCAC MILITARY & VETERANS OFFICE
Phone: 412.237.6503
Fax: 412.237.2765
Email: veteransservices@ccac.edu
STUDENT TYPE
New Returning
Guest Transfer
CAMPUS
Allegheny Boyce
North South
TERM
FALL SPRING
SUMMER YEAR_______
CHAPTER
30/34 31 33
35 1606
BRANCH OF SERVICE
USAF USA USCG
USMC USN
Reserve National Guard 
Are you currently on Active Duty? Yes No   Are you going to be using Military Tuition Assistance? Yes No
Have you taken any college courses prior to enrolling at CCAC? Yes No 
click to sign
signature
click to edit
Chrome Web Store
It looks like you haven't installed the Fill Chrome Extension Add to Chrome