Request for Certification

REQUEST FOR CERTIFICATION

Office of Veterans Affairs
222 Schiavo Hall

Penn State Hazleton

76 University Drive

Hazleton, PA 18202

Phone: 570-450-3163

NAME: ______PSU ID #______

PERMANENT HOME ADDRESS: ______

LOCAL ADDRESS, IF DIFFERENT FROM ABOVE: ______

LOCAL/CELL PHONE: (______)______HOME PHONE: (_____)______

EMAIL ADDRESS: ______DATE OF BIRTH: ____/____/______

MAJOR: ______VA FILE NUMBER: ______

VA STATUS (Please check one.)

______Montgomery GI Bill (Chapter 30)

______Post 9/11 GI Bill (Chapter 33)

______Dependent (Chapter 35) VA CLAIM # (If known): ______(Ch. 35 Only)

______Reservist/National Guard (Chapter 1606)

______REAP /Reserve Educational Assistance Program (Chapter 1607)

Which semesters do you wish to receive benefits? (Check all that apply)

______Summer Semester 2016-- Number of Credits ______

______Fall Semester 2016 -- Number of Credits ______

______Spring Semester 2017 -- Number of Credits ______

Have you used veteran education benefits before? ______YES ______NO

______

(Student signature) (Date)

I wish to receive advance payment for the ______semester 20______.

______

(Student signature) (Date)

Note: Advance payment for Fall Semester 2016 should be requested by July 1, 2016.