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.
Mailing Address: Street City State Zip
Telephone #: Date of Birth: Email Address:
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 NursingAAS-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
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.