VA Enrollment form


VA Enrollment Form

Student Information:
  First Name:  (Required)
  Last Name:  (Required)
  Birthdate:  /   /                    [mm/dd/yyyy](Required)
  Student ID:   (Required)

Contact Information:

  Email address:
  Address Line 1: (Required)
  Line 2:
  City:   (Required)
  State:   (Required)
  ZIP:   (Required)

Select one of the following that best describes your status: (Required)

    I am a new student transferring credits from another University or College and I have used my benefits before. (also fill out form 22-1995 or 22-5595)
  I am returning to FTCC after not having attended for at least one semester (including summer).
  I am a continuing student at FTCC, who attended the previous semester.
  I have not used my VA benefits in at least one year at FTCC.
  I am a new VA student that has never used VA benefits.

What degree will you be working towards this semester? (Required)

  Visiting Student
    What program have you been approved into? 

Is this a change from last semester?                    Yes   No (Required)

Type of benefits that you receive? (Required)

  Chapter 33, 9-11 GI Bill
  Chapter 30, Montgomery GI Bill
  Chapter 1606, Reservist GI bill
  Chapter 1607, Reserve Educational Assistance Program
  Chapter 31, Vocational Rehab
  Chapter 35, Dependents, VA Claim Number:
  Chapter 32, VEAP

Semester(s) of enrollment for certification: (Required)

  Fall 16 Weeks Year:   Credit Hours:
  Fall 1st 8 Weeks Year: Credit Hours:
  Fall 2nd 8 Weeks Year: Credit Hours:
  Spring 16 Weeks Year: Credit Hours:
  Spring 1st 8 Weeks Year: Credit Hours:
  Spring 2nd 8 Weeks Year: Credit Hours:
  Summer Year: Credit Hours:

Is this to verify that you want to be certified for the above periods?
                       Yes   No (Required)

Have you read the FTCC VA Student Rules & Regulations?
                  Yes        No (Required)