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Veterans Educational Benefits Coordinator Card
Please fill out the coordinator card.
Applying for VA benefits under:
Applying for VA benefits under:
required
MGIB/Chapter 30 Active Duty
MGIB/Chapter 30 Non-Active Duty
VA Vocational Rehabilitation Chapter 31
MGIB Post 9/11 GI Bill/Chapter 33
MGIB Post 9/11 GI Bill Transfer Of Entitlement/Chapter 33
Dependent/Spouse of Disabled Veteran/Chapter 35
MGIB Reserves/Chapter 1606
MGIB Reserve Ed. Asst. Program/Chapter 1607
Presently in Service
Presently in Service
required
Yes
No
National Guard Tuition & Fee Contract
National Guard Tuition & Fee Contract
required
Yes
No
Are you receiving a Kicker?
Are you receiving a Kicker?
required
Yes
No
If so, what chapter?
If so, what chapter?
30
1606
1607
If so, amount per month
First Name
required
Middle Name
required
Last Name
required
VA File Number Including Suffix Letter - Chapter 35 Only
WVU ID Number
required
VA Check Mailing/Permanent Address-Street, City, State, Zip Code
required
Check here if the previous address entered is a change of address that needs to be submitted to the Department of Veterans Affairs
Check here if the previous address entered is a change of address that needs to be submitted to the Department of Veterans Affairs
Change of Address
Phone Number
Example: (555) 555-5555
Local Campus/Address where you live in Morgantown
Street, City, State, Zip Code
required
Phone Number
required
Example: (555) 555-5555
E-mail Address
required
MIX Email Address Only
Prior Credits
Total Credits completed toward degree:
Cumulative GPA
Degree Presently working for
Example: B.A.
required
Major
Example: General Studies
required
Check here if this is a change in Program (major) or Place of Training (institution). If this is a change in Program or Place of Training, please complete Form 22-1995/22-5495. ***STOP HERE. You’ll need to make an appointment to see one of the VA representatives
Check here if this is a change in Program (major) or Place of Training (institution). If this is a change in Program or Place of Training, please complete Form 22-1995/22-5495. ***STOP HERE. You’ll need to make an appointment to see one of the VA representatives
change in Program (major) or Place of Training (institution)
Type of Training
Type of Training
required
Undergraduate Degree
Graduate/Advanced Professional Degree
Are you receiving Reserve Tuition Assistance? (not National Guard)
Are you receiving Reserve Tuition Assistance? (not National Guard)
required
Yes
No
Are you receiving ROTC benefits?
Are you receiving ROTC benefits?
required
Yes
No
Are you receiving ACES?
Are you receiving ACES?
required
Yes
No
Credit Hours: List only the hours you want to be certified for. If you do not want to be certified, list 0 hours.
Summer 2013 (5/20/13-8/9/13)
required
Credit Hours: List only the hours you want to be certified for. If you do not want to be certified, list 0 hours.
Fall 2013 (8/19/13-12/19/13)
required
Credit Hours: List only the hours you want to be certified for. If you do not want to be certified, list 0 hours.
Spring 2014 (1/8/14-5/3/14)
required
Will any of the hours listed in the previous question be D/F Repeats?
Will any of the hours listed in the previous question be D/F Repeats?
required
Yes
No
Anticipated Date of Graduation
required
Example: MM/DD/YYYY
Today's Date
required
Example: MM/DD/YYYY
IF YOU ARE SUBMITTING THIS FORM ELECTRONICALLY, PLEASE CHECK THE BOX AS YOUR ELECTRONIC SIGNATURE
IF YOU ARE SUBMITTING THIS FORM ELECTRONICALLY, PLEASE CHECK THE BOX AS YOUR ELECTRONIC SIGNATURE
required
Electronic Signature