SRJC Veterans Affairs Certification Request

This form must be submitted each semester you wish to use your VA educational benefits. Any time you make a change to your schedule, you must submit a new form. VA will not pay for courses that are not required to complete your program of study. VA will not pay for repeat coursework unless a higher minimum grade is required.

Name*

First Name

Last Name

Student ID Number

Phone*

Email*

Benefit Chapter*

30 31 33 1606 35

if 35, VA File Number

Have you completed your FAFSA application for financial aid?*

Yes No

Are you receiving the California Free Waiver for Dependents?*

Yes No

Program of Study*

Has your major changed since you were last certified to VA?*

Yes No

Is this a schedule change?*

Yes No

Check appropriate semester/term. Complete a new for for EACH semester/ term.

Fall Spring Summer

Input your schedule below. Please be sure each subject includes course number, number of units and note whether you are repeating the class or not.