Student Records Office

VA Request for Certification
Print the form, complete it, and send to the Office of Student Records (800 Lakeshore Drive, Birmingham, AL 35229-7030), or fax it to (205) 726-2908. PLEASE TYPE OR PRINT CLEARLY.


 Name: _________________________________________________________
                                           Last                                              First                                              Middle

 Banner SUid or SSN: ___________________ VA File Number: _______________
                                        


 Mailing Address: _________________________________________________

 ______________________________________________________________

 City: ____________________________ State: __________ Zip: ___________

 Phone: (_____) ______________


 Class Status: _____ FR _____ SOPH _____ JR _____ SR _____ GRAD

 Major: _________________________ Minor: _________________________

 Has your major changed? _______

 (If yes, you must file a 22-1995 or 22-5495 form in the Student Records Office.)
VA Benefit:
Please certify me for the following terms:


  ____ Chapter 30          (MGIB - ACTIVE DUTY)

  ____ Chapter 31          (VOC REHAB)

  ____ Chapter 32          (VEAP)

  ____ Chapter 33          (Post 9/11 GI BILL)

  ____ Chapter 35          (SURVIVORS/DEPENDENTS)

  ____ Chapter 1606      
            (MGIB - NATIONAL GUARD _____ RESERVES _____)

  ____ Chapter 1607      
            (RESERVE EDUCATIONAL ASSISTANCE PROG-REAP) 

  ____ Summer I 2009

  ____ Summer II 2009

  ____ Summer 10-Week Term 2009

  ____ Fall 2009
 
  ____ Spring 2010
 
  ____ Jan Term 2010
STATEMENT OF UNDERSTANDING
I fully understand that I must report any changes to the VA Certifying Official immediately. I am aware that changes in my enrollment status may alter the payment the VA will award me. I also understand that I will be held liable for any overpayment that I might receive from the VA.



 Signature: ____________________________________ Date: ____________



Page maintained by Jane Leask, Assistant Registrar (Certifications, Publications, & Programming), jeleask@samford.edu.
Last update: 7/7/09 10:12 AM
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