Veteran Request for Enrollment Certification

Please complete all requested information and return this form to the AWC Veteran Services Office fax :(928)344-7543; or by email to

This request is for the following semester (one per semester) Please check one: Fall Winter Spring Summer Year 20_____

Personal Information

XXX-XX-

Last Name First Name MI Student ID# VA File #

Street Address City State Zip Code

Phone Number Are you an Arizona resident? Yes No

*you may qualify for in-state tuition & fees rates. See the VSO.

Student Information

Please mark the appropriate information below:

Is this your first time using VA educational benefits: YesNo Are you transferring from another school: Yes No

Is this a revision of a previous request: Yes No Are you taking courses at another school: Yes No

Do you currently receive any Financial Aid, Scholarships or Awards? YES NO If so what is the Source? ______

Degree Sought (A.A.S, CERT. etc) Major

Are you repeating any classes? Yes No

Course# (eng-101-001) / Credit Hours / Online Course / Select One / Course# (eng-101-001) / Credit Hours / Online Course / Select One
Add / Drop / Add / Drop

Affiliated Branch of Service Air Force Army Coast Guard Marines National Guard Navy

Veteran Education Benefits Information

Which VA Education Benefit Program are you requesting to be certified under this semester?Please see the back of this form or visit learn whicheducation benefit is best for you:

Chapter 30 - Montgomery GI Bill Chapter 31 - Vocational Rehabilitation Chapter 35–Dependent’s Education Assistance

Chapter 1606 - Reserve/National Guard (NOBE required) Chapter 1607 - (Reserve/National Guard )(NOBERequired)

Chapter 33 - Post 9/11 GI Bill → Is this for Transfer of Entitlement? Yes No

Terms and Conditions

ALL COURSE WORK MUST BE REQUIRED FOR THE DEGREE IN ORDER TO USE VETERANS BENEFITS. FOR ALL FAILING GRADES, THE INSTRUCTOR WILL BECONTACTED FOR LAST DATE OF ATTENDANCE. NOT ATTENDING CLASSES MAY AFFECT YOUR TOTAL BENEFIT.

Reduction in course enrollment after certification will be submitted to the VA and may result in the retroactive loss of benefits unless the VA finds mitigating circumstances involvedin the change. Loss of benefits could revert back to the first day of class.

INITIALS

I AM AWARE THAT CHANGES IN MY REGISTRATION MAY ALTER THE VA PAYMENTS I AM AWARDED.

I UNDERSTAND THAT I WILL BE LIABLE FOR ANY OVERPAYMENT I MIGHT RECEIVE FROM THE VETERANS

ADMINISTRATION. I ALSOUNDERSTAND THAT I MUST NOTIFY THE VA CERTIFYING OFFICIAL AND THE VETERAN

AFFAIRS ADMINISTRATION OF ANYCHANGES IN MY REGISTRATION.

I AM AWARE THAT I MUST COMPLETE THIS FORM FOR EACH TERM IN WHICH I WISH TO BE CERTIFIED

AFTER I HAVE REGISTERED OR MADE CHANGES FOR THAT TERM.

I AM AWARE THAT I AM RESPONSIBLE FOR ANY TUITION/ FEES NOT PAID FOR BY THE VA.

Signature Date

I hereby certify that all statements are true and complete to the best of my knowledge. I give AWC permission to request military transcripts on my behalf.