Veteran Certification Information Card If you would like confirmation of receipt of the Veteran Certification Card, please email Veteran Affairs Representative at veteranaffairs@pierpont.eduSemester/Term(Required) Spring Summer FallBenefits Requested(Required)Post 9/11 / Chapter 33Post 9/11 / Chapter 33 DependentVoc Rehab / Chapter 31Active Duty / Chapter 30WV Re-Ed ScholarshipREAP / Chapter 1607Reserve / Chapter 1606Guard / Chapter 1606Dependent of Disables Veteran / Chapter 35Go Army Ed TA - HQ Air Force Reserve TAPost 911/VRRAPName(Required) First Middle Last 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 Phone(Required)Email(Required) Student ID (R Number)(Required)Degree(Required) Associate's CertificateExpected Graduation Date(Required)MajorNumber of Hours Registering For(Required)Please choose from the following:(Required) This is my first time using my VA Education Benefits at PCTC. I have used my VA Education Benefits at PCTC.You must select yes in order to submit this application.(Required) Yes, I acknowledge that this form has been completed fully and to the best of my knowledge.In order to be certified with the VA, you must complete this certification form every semester. Change in dependent status must be reported directly to the VA Regional Office in Huntington, WV. By confirming above and submitting this form, you agree to the following : "I understand that any changes in my educational status, i.e. a drop in credit hours, withdrawal from college, suspension, or a change of program must be reported to the Pierpont Community & Technical College Veteran Certifying Official and the VA. I, also, understand I will be responsible for repaying to the VA any benefits received by myself or paid to the school on my behalf that I am no longer eligible for due to but not limited to the previously stated reasons." CAUTION: A student who willfully submits a false report to obtain benefits may be prosecuted, resulting in fines, imprisonment or both.Signature (Full Name)(Required)If you would like confirmation of receipt of the Veteran Certification Card, please email Veteran Affairs Representative at veteranaffairs@pierpont.edu
