Veterans Verification of Enrollment Form

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

For use of Chapter 35 DEA Benefits, please provide the File Number. This is the Veteran's social security number.

For Chapter 35 DEA Benefits, please provide the FIRST and LAST NAME of Veteran with 100% disability

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? If NO, you must apply for a Certificate of Eligibility with VA to use establish use of your benefit. *

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 RETIRED Veteran) These are benefits I earned during my time of service (I am an ACTIVE SERVICE Veteran) These are benefits transferred to me from a parent who has served (I am a DEPENDENT) These are benefits transferred to me from my spouse (I am a 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 a member of our MS National Guard, are you planning to use SEAP benefits in conjunction with Chapter 33 benefits? If yes, this will decrease your SEAP payout by 50%. SEAP Benefits are awarded on a LIMITED BASIS for AVAILABILITY. Apply for this benefit AS SOON AS the window opens!

Yes No

Do you plan to use Federal Tuition Assistance in addition to your VA Education Benefit?

Yes No

If you answered yes to use of Federal Tuition Assistance, please indicate the dollar amount $$ on the line below.

Note: Any Federal Tuition Assistance used must be subtracted from the amount of Mississippi College tuition submitted to V.A. for Chapter 33 benefits

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 RESERVIST 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: *

Fall 2024 Spring 2025 Summer 2025 Fall 2025 Spring 2026 (Includes Winter Term Session)

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 *

7. Expected Graduation Date If graduating this selected term, be sure to APPLY TO GRADUATE (Instructions and Info available on MC's website) *

6. Current Degree/Major *

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 *