Veterans Intake Form
Name____________________________________________Student # __________________________________
Address ____________________________________________________________________________________
Phone #___________________Email Address___________________________Semester/Year_______________
□ Ch 33 Post 9/11 G.I. Bill □ Ch 31 Vocational Rehab □ VRAP
□ Ch 33-TOE □ Ch 1606 Guard/Reserve
□ Ch 35 Dependent/Survivors □ Ch 30 Montgomery G.I. Bill
Current Objective: Please indicate intended major and goals. Must be a degree or certificate program offered
through CRC or a CSU/UC transfer program.
□ Certificate Major_____________________
□ AA or AS Degree Major_____________________
□ Transfer Major_____________________ Transfer Institution__________________
*Are you interested in information below (check all that apply)?
Disability Support Services
Official Transcripts – Official transcripts from all previous colleges and universities attended MUST be on file
prior to making appointment with counselor for VA Educational Planner.
I understand that my VA Educational benefits may be affected if relevant information is withheld and if changes
in educational status are not reported.
Signature__________________________________ Date__________________________
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OFFICE USE ONLY:
DD-214 (member 4 copy)
Certificate of Eligibility (COE)
VA Application (VA form 1990, 5490, 1995 or 5495)
CRC VA Statement of Understanding Form
CRC VETERANS AND DEPENDENTS ENROLLMENT STATUS FORM
VA EDUCATION PLAN Date:______________
Veterans SSN_______________ Dependent # ____________
DND posted for Chapter 33, 33-TOE and 31
Priority Registration (Chapter 33, 33-TOE and 31 only)
6/2019
Once the forms are completed, students may send from their Los Rios email account to: YangJ@crc.losrios.edu
for processing.
