Name (First, Middle, Last) SSN Student ID
Mailing Address Primary phone DOB
City State Zip Email:
Chapter 30 (MGIB) Chapter 31 (Voc Rehab) Chapter 33 (Post 9/11) Chapter 1607 (REAP) Chapter 1606(Guard/Reservist)
Chapter 33 (Post 9/11) transferability
Chapter 35 (DEA) (VA Claim # /Child # )
First Time Using Benefits? Yes No If no, previous school:
Program of Study: (Ex: BA/History)
Yellow Ribbon (Chapter 33 only) Out of state residency
100% eligibility rating Active duty status
YES NO
YES NO
YES NO
Choice Act (Chapter 33 only)
ETS Service within 3 years of starting school | Submitted DD214 for verification | ETS date (DD214): |
NOT Active Duty |
Tuition Assistance (Chapter 1606 only):
Will be receiving TA and understand I will not be eligible for GI Bill benefits and/ or TA may affect my tuition and fee payment under Post 9/11 Chapter 33
Signature:
Date: