Veteran Enrollment Certification Form

To request certification, please complete this form. If you have any questions, please email va@untdallas.edu or visit the Veterans Success Center on the second floor of Founders Hall (FH).

Please allow 7-10 business days for your certification to be submitted.

Please fill out this form COMPLETELY to avoid delays in payment!

First Name *

Last Name *

UNTD ID Number *

example: 12345678

Email Address *

Student Status *

Transfer Students *

List the last school where VA education benefits were used.

Mailing Address *

City *

State *

Zip Code *

Home Phone *

Cell Phone *

Major *

Degree *

Expected Graduation Date *

(i.e. semester and year; ex. Fall 2023)

Have you changed your major/degree plan since last semester? *

If yes, what was your previous major? *

What is your major now? *

22-1995/22-5495 *

Have you completed the 22-1995 (Request for Change of Program or Place of Training) OR 22-5495 (Dependent's Request for Change of Program or Place of Training)?

VA Chapter *

Percentage *

VA File No. (Chapter 35 ONLY) *

Hazelwood *

Are you using Hazlewood?

Semester *

For which semester are you submitting this form?

Year *

Month

Day

Year

Total Hours Enrolled *

Internet Courses *

List number of hours.

Repeat Courses *

List each course (ex. ENGL1902 Freshman English).

Read and Initial *

Please read each item and select the option, which serves as your initial on this form, and states that you understand each statement and your level of responsibility for each.

	I understand.
I Understand that I must complete this form, the VA Enrollment Certification Form EACH SEMESTER AFTER I register. *	I Understand that I must complete this form, the VA Enrollment Certification Form EACH SEMESTER AFTER I register. - I understand.
Post 9/11 students: I will submit a copy of my VA Award letter or Education Enrollment Status (eBenefits) in order to certify my enrollment and receive my benefits each semester. *	Post 9/11 students: I will submit a copy of my VA Award letter or Education Enrollment Status (eBenefits) in order to certify my enrollment and receive my benefits each semester. - I understand.
I understand ONLY courses required on my degree plan will be certified for VA education benefits. *	I understand ONLY courses required on my degree plan will be certified for VA education benefits. - I understand.
I will inform the Certifying Official of ANY AND ALL CHANGES that I make to my schedule. *	I will inform the Certifying Official of ANY AND ALL CHANGES that I make to my schedule. - I understand.
I understand Veterans Affairs (VA) will hold me responsible for any overpayment of my education benefits as a result of dropping courses, non-attendance, withdrawing from UNTD, etc. *	I understand Veterans Affairs (VA) will hold me responsible for any overpayment of my education benefits as a result of dropping courses, non-attendance, withdrawing from UNTD, etc. - I understand.
I am responsible for paying any remaining balances on my account or risk being dropped from my classes. I am responsible for checking https://my.untdallas.edu for remaining account balances for tuition and fees that are not covered by my VA education benefits. (Ex: application fee, orientation fee, late registration fee, parking permit, parking tickets, out of state tuition/fees, excess hours charges, repeat course fees.) *	I am responsible for paying any remaining balances on my account or risk being dropped from my classes. I am responsible for checking https://my.untdallas.edu for remaining account balances for tuition and fees that are not covered by my VA education benefits. (Ex: application fee, orientation fee, late registration fee, parking permit, parking tickets, out of state tuition/fees, excess hours charges, repeat course fees.) - I understand.
I understand that benefit payments are always paid one month in arrears and initial payment of benefits may sometimes be delayed at the Regional VA Processing Office due to workload. *	I understand that benefit payments are always paid one month in arrears and initial payment of benefits may sometimes be delayed at the Regional VA Processing Office due to workload. - I understand.
I authorize the release of all academic records and information by UNTD to the Veterans Administration. *	I authorize the release of all academic records and information by UNTD to the Veterans Administration. - I understand.
I certify that I am enrolled in courses for each semester/term listed above and the information is true and correct. *	I certify that I am enrolled in courses for each semester/term listed above and the information is true and correct. - I understand.

Signature *

This section serves as your digital signature. Please type your first and last name in the space below.

Date *

Month

Day

Year