VA Educational Benefits Request

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Full Name:  Last:*     First:*     Middle:
Wake Tech  Email:*   
Social Security Number:* XXX-XX-  
Date of Birth:*   
VA File Number
(for dependents only 
VA Chapter:*    
Former military branch or present reserve branch:*    
Curriculum Title (program): *    
Mailing Address:*  Street Address City
State: Zip
Telephone:* (home)  (work) 
Please check: I request certification for VA Educational Benefits in the 2016-2017 school year for the terms checked below:   
  (Please check all that apply):    
  Fall 2016    Spring 2017    Summer 2017   
  Do Not certify me for the following terms:      
  Fall 2016    Spring 2017    Summer 2017     
  Will you receive Tuition Assistance from the military?*    Yes     No  
Are you currently on active Duty?*    Yes    No    Date of Discharge
Advance Payment Request: Yes    No   There must be a 30-day break between terms before requesting.
*Request excludes Post-9/11 GI Bill
Advance Payment requests should be submitted to this office by the following dates: Fall - July 8, 2016
Spring - December 2, 2016
Summer - April 7, 2017
    I understand enrollment will not be submitted to VA until I am registered for courses.
  I understand, if applicable, I must verify attendance at the end of each month.
  I will comply with VA and College regulations regarding Drops, Withdrawals, and Termination of registration.
  I understand that I will not be paid for courses not in my curriculum.
  I understand I will not be paid for courses challenged or audited.
  I understand I will not be paid for Pre-curriculum courses taught online.  
I acknowledge the information provided is accurate. Should any information change, I will notify the VA Office in writing. I agree to adhere to policies and procedures set forth by both Department of Veterans Affairs and Wake Technical Community College.  
Student's Signature*  Date: