Personal Information First Name * Middle Initial Last Name * Address * SSN * MC ID 700# * Email Address * Phone Number * Date of Birth (mm/dd/yyyy) * VA Education Benefit Information Select and Complete the Chapter authorizing your benefits. * Chapter 1606 MGIB-Selected Reserves or National Guard Chapter 30 MGIB-Active Duty (contributed to education fund while on active duty) Chapter 31 Vocational Rehabilitation and Employment Chapter 35 Survivors' & Dependents' Education Assistance (DEA) of disabled or deceased parent. Chapter 33 Post 9/11 (Please also check appropriate box and answer questions below for this chapter) Fry Scholarship Marine Gunnery Sergeant John David Fry Scholarship If you chose Chapter 35, please provide the File Number. This is benefit donor's social security number. If you chose Chapter 35, please provide the Payee Number. typically a number following your file number. If you chose Chapter 33, What percentage of the benefits are you eligible? (not the number of months of eligibility) 100% Yellow Ribbon 90% 80% 70% 60% 50% . Have you previously used this VA benefit? Note: If no, you must apply with VA to use benefits. * Yes No Are these your earned benefits from your time of military service (Veteran) or were these transferred to you (Dependent or Spouse)? These are benefits I earned during my time of service (I am Veteran, either active or retired) These are benefits transferred to me from a parent who has served (Dependent) These are benefits transferred to me from my spouse (Veteran's Spouse) If you are a Veteran, using benefits you have earned serving in our US Military, what branch did you serve under? Army Air Force Marine Corps Navy Space Force Coast Guard Active and Reservist Inquiry If you are currently serving in a Reserve or Active capacity, please indicate which component you are serving in: Army National Guard Air National Guard Army Reserve Navy Reserve Marine Corp Reserve Do you plan to use Federal Tuition Assistance in addition to your VA Education Benefit? Yes No If you answered yes to the above question AND chose Chapter 33, please indicate the amount $ Note: Any tuition assistance used must be subtracted from the amount of Mississippi College tuition submitted to V.A. Please note that we must have a signed FERPA from each student planning to use TA. Complete and return the FERPA form to the Office of the Registrar, Nelson Hall or mail to PO Box 4028, Clinton, MS 39058. ONLY IF you are serving in an active or reserve capacity would you like to establish eligibility for MC's Reduced Military Rate. (This rate is not applicable to all programs of study. Information is found on MC's website for further details.) Yes, I would like to be contacted to establish eligibility for MC's Reduced Military Rate APPLICABLE ONLY TO ACTIVE AND RESERVIST STATUS MILITARY No, I am not interested in establishing eligibility for this benefit Academic Information 3. I am requesting certification for term: * Summer 2023 Fall 2023 Spring 2024 Summer 2024 Fall 2024 4. Have you attended MC before? * Yes No If yes, last term/year attended. 5. List the registered courses you desire VA to pay tuition for. Note: VA only pays for courses required for your degree. Please include the Course Name, Course Number, Hours, and Required (Y/N) * Are you registered for an externship, internship or clinical course? * Yes No If you answered yes to the above question, please provide the zip code of the site. Total Number of Hours * 6. Current Degree/Major * 7. Expected Graduation Date If graduating this selected term, be sure to APPLY TO GRADUATE (separate form) * Note: A transfer student continuing your benefits or changing degree program must submit a VA Form 22-1995 or VA 22-5495 using the VONAPP website. A continuing MC student changing major may submit a paper copy to our office. 8. My Program of Study is: * Undergraduate Graduate Law Signature In leiu of your signature, please check this box and type your full name below. * Full Name for Signature *
