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 Enrolled In(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 do 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.

Student Information

Academic Information

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