Veteran Certification Request Form

Student Information

VA File Number(Required)

Student ID(Required)

Date of Birth(Required)

Name(Required)

First Middle Last

Mailing Address(Required)

Street Address Address Line 2 City State ZIP Code

Email(Required)

Phone(Required)

I receive benefits under(Required)

Academic Information

UMPI Degree Program

(if a degree candidate at UMPI)

Institution Name

(if NOT a degree candidate at UMPI)

Are you a new UMPI Student?(Required)

Yes

Semester of Certification(Required)

Credits(Required)

Are you taking classes off-campus or online at another institution?(Required)

Yes

Name of other institution(Required)

By submitting this form, I acknowledge my obligation to notify the School Certifying Official of any change in my course schedule. I understand that failure to to so will result in my being personally liable to the Veterans Administration for overpayments and could result in a delay of benefits for future semesters.

Name

This field is for validation purposes and should be left unchanged.

Veteran Certification Request Form

Student Information

Academic Information

Lisa Smith

Nola Belanger

Barbara Lambert