Cleary University

VA Request for Certification


TERM/YEAR: /  

STUDENT IDENTIFYING INFORMATION

FULL NAME (Student)
STREET ADDRESS
CITY & STATE  
ZIP CODE
PHONE NUMBER
E-MAIL ADDRESS
VA FILE # / SS# (Veteran)*
SOCIAL SECURITY # (Student)
DATE OF BIRTH
*if you are using dependent benefits

PROGRAM NAME & MAJOR  

VETERAN BENEFIT INFORMATION

I am claiming the following benefit: (Select One)

Are you currently on Active Duty?  

Completion of this form authorizes the Cleary University Records Department to certify my enrollment and provide academic record information to the Department of Veterans Affairs to initiate processing of educational training benefits. I understand that I must complete this form EACH SEMESTER before my enrollment will be certified, and that submission of the certification does not guarantee payment of benefits. It is my responsibility to notify the Records Department immediately upon adding, dropping or withdrawing from a course, and I understand that the Records Department will also report and changes to my enrollment status.

I HAVE READ AND UNDERSTAND THE ABOVE POLICIES AND PROCEDURES.

Leave this empty:

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Signature Certificate
Document name: VA Request for Certification
lock iconUnique Document ID: 1df1b7b181e5cb947864bd08ba5ac967a4a81132
Timestamp Audit
October 29, 2020 4:12 pm EDTVA Request for Certification Uploaded by Michael Thompson - michael@yourppl.com IP 75.128.132.184