Veterans Certification Form

The completion of this form authorizes Missouri State-West Plains to provide required information and to certify your enrollment for a specified semester to the Department of Veterans Affairs, St. Louis, MO.

Name: M#:

Mailing Address: Street City State Zip

Telephone #: Date of Birth: Email Address:

Please check the appropriate category:
CH 30 New Montgomery G.I. Bill – Active DutyCH 31 Disabled Veterans/Vocational Rehabilitation
CH 32 VEAP – Veterans Educational Assistance ProgramCH 1606 New Montgomery G.I. Bill Selected Reserve/National Guard
CH 33 Post-9/11 Veterans Educational Assistance ActCH 1607 REAP – Reservists called to active duty after 9/11/01
CH 35 Survivors/and Dependents Education Assistance Program – File #: and Payee #:

Check the degree you are seeking: AA AS AAS Name of Major:
AA-Associate of Arts in General Studies AA-Associate of Arts in Teaching AS-Associate of Science in Nursing
AAS-Associate of Applied Science in: Business, Child and Family Development, Computer Graphics and Programming, Computer Technology, Enology, Entrepreneurship, General Agriculture, General Technology, Law Enforcement, Respiratory Therapy, Viticulture

Select Semester: Fall Spring Summer Year

Have you changed your major and/or your place of training since your last certification request? Yes No
• If yes, you must complete a Change of Program or Place of Training form (22-1995) on the VA website

Benefit Application Status:

  • Continuing Student: Have received benefits before at Missouri State University-WP
  • New Applicant: Applying for VA benefits for the first time
  • Transfer Student: Transferring from another institution where I used veterans benefits

Class Schedule

Begin Date-End DateCourse CodeCourse #Credit HoursRepeat

I understand that…

I must be a degree-seeking student in order to receive benefits.The following may affect the monthly dollar amount of educational benefits:
  • Dropping or adding classes
  • Enrolling in an unauthorized repeat of a class
  • Enrolling in courses that do not apply towards your program of study, or
  • Enrolling in classes with various beginning and ending dates such as intersession classes, LWE classes and certain summer classes.
I must file a copy of my DD214 with the VA Certification Official and the Admissions Office in order to receive credit evaluation for military training.
It is my responsibility to notify Veterans Services if I make changes in my class load, which will affect my enrollment status and rate of pay.
I must attend class and make satisfactory progress.
If I have questions regarding my VA eligibility or payment amounts, I should call the Department of VA at (888) 442-4551.

My signature below indicates that I understand the above guidelines and that I must complete a new Veterans Certification Request form each semester in order to receive veterans’ educational benefits.

 

  

Student Signature Date