Fall 2017 Request for Benefits
Last Name
Your answer
First Name
Your answer
Student ID#
Your answer
Phone Number
Your answer
Email Address
Your answer
Street Address
Your answer
Your answer
Zip Code
Your answer
Degree Objective
2nd Major
Your answer
Transfer School
Which Educational Benefit are you utilizing
Are you requesting advanced pay? (Only Ch 30 & 35)
Will you pay health health fee?
Have you read and agree to adhere to the Standard of Student Conduct?
I certify that all information is complete and correct. I agree to inform The Veterans Service Office of any changes in my enrollment status (adding/dropping certified class). I understand that failure to do so may result in me owing a debt to the Veterans Administration.
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