Student InformationVA File Number(Required) Student ID(Required) Date of Birth(Required)Month123456789101112Day12345678910111213141516171819202122232425262728293031Year2025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Name(Required) First Middle Last Mailing Address(Required) Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Email(Required) Phone(Required)I receive benefits under(Required)New Montgomery (Chapter 30)Vocational Rehabilitation & Employment (Chapter 31)Post 9/11 (Chapter 33)Survivor & Dependents (Chapter 35)Reserves & National Guards (Chapter 1606)REAP (Chapter 1607)Academic InformationUMPI 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 No Semester of Certification(Required) Credits(Required) Are you taking classes off-campus or online at another institution?(Required) Yes No 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.NameThis field is for validation purposes and should be left unchanged.