VA – Online Request for Certification

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Complete this form each semester for which you enroll and want to be paid.
Courses previously completed and passed cannot be re-certified for payment.
It is your responsibility to report class changes or withdrawals to the certifying official and the VA as they occur.
Any classes listed on this form for payment must be degree applicable and listed on your student education plan provided by an Academic Counselor!

"*" indicates required fields

Term of Certification *

Please Select a Term.

Guest Student

Yes

Select "Yes" if you are a guest student.

Home Campus

Please tell us which campus you're from.

Name *

First Last

Enter both your first and last name.

Student ID. *

Please enter your student ID. If you do not have a student ID please contact theAdmissions Office

Email *

Phone *

Please enter your phone number.

VA File Number *

(Dependent/Spouse please list SSN of Veteran)

VA Chapter Code *

Is this a new major?

Yes

Select Yes, if this is a new major.

Course Data

Add one or more courses.

Courses

Course Name	Course Number	Units	Start Date	End Date	Add/Drop	Class Type	Actions

There are no Courses.

Add one or more Courses.

Comments and Agreement.

Comments

If you have any comments please enter them above.

Agree to Terms *

Agree

I certify that:
• I am aware that only courses that are required for my degree objective will be certified.
• I am aware that changes in my course enrollment and length of term of my courses may alter the payment the VA will award me.
• I understand that I will be responsible for any overpayment I might receive for all unreported withdrawls or FW grades.
• I am aware that I must fill out this form each semester after registering for classes.
• I am aware that the certification process may take up to 14 days, so I am responsible for ensuring that I submit this request prior to the term payment deadline.

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VA – Online Request for Certification

Course Data

Comments and Agreement.

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