Veterans Request for Benefits Form

*PVCC continuing students only should complete this form. All new applicants to
VA benefits at PVCC must contact our Veteran Services Office.*

	First Name Last Name
Name:
Social Security Number:
V.A. File Number:
Address:

	City: State: ZIP:
Country:
Home Phone Number:
Work Phone Number:
Email address:

I am requesting Veteran's Benefits under the following Chapter: (select one only)

Active Duty
CH 30-New GI Bill
CH 31-Voc. Rehab.
CH 35-Dependent of Veteran (wife, child)
CH 106-Reserves
CH1607- Selected Reserves

All students must complete this section:

Is PVCC your parent school? Yes No
If not, who is?
Will you be attending more than one school this semester? Yes No
If yes, where?

Which semester and year are you requesting your benefits for?

If you are new to PVCC complete this section:

Which Associate Degree Program are you pursuing at PVCC? (check one only)
AA-Associate of Arts Degree
AGS-Associate of General Studies Degree
AAS-Associate of Applied Science Degree
CCL-Certificate of Completion
College you intend to transfer to:
Name of transfer program:
List all institutions you have previously attended:

Are the above transcripts on file in the PVCC Admissions Office? Yes No
*You have one semester to have your official transcripts sent from previous schools to PVCC.

List all the courses you will be taking at PVCC this semester

Subject Code	Section	Title	Credits	Start Date	End Date

Repeated Courses
The VA will not pay for a repeated course unless the course is required for completion of your program. No course may be repeated where a grade of "C" or better has been received.

The VA Will Pay for: A's, B's,C's,D's P's
The VA May Pay for F's and Y's depending on attendance.
The VA will not pay for: R's (withdrawals), W's (withdrawals), Z's (no credit)

By submitting this form I certify that all schools previously attended have been listed and that I will request official transcripts to be sent to the Veteran's Office at PVCC immediately. I understand that failure to provide these transcripts can result in overpayment by the V.A. or interrupt my educational benefits.

Please notify the Veteran's Office if you have changes in the above information. Incomplete forms will not be accepted.

Last updated: August 28, 2006
Paradise Valley Community College- URL-http://www.pvc.maricopa.edu/veteranrequestform.html
© 2006 Maricopa County Community College District. All Rights Reserved.
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