Semester Certification Form

This form must be used each semester to notify the Veterans Compliance Coordinator of the following options:

• You have registered for classes and request VA certification
• You are submitting courses that do not fall directly into your degree plan, but have evidence of pre-requisite for future classes
• Notification of degree plan change which also requires submission of the Major Change Form to Registration using this link in addition to completing this form below.

Semester Certification Form

Personal Information

First Name *

Middle Name

Last Name *

Maiden or Former Name

Phone Number *

Dixie ID

Dmail Address *

Semester

Semester you are requesting VA benefits for * Fall 2015 Spring 2016 Summer 2016 Fall 2016 Spring 2017 Summer 2017 Fall 2017 Spring 2018 Summer 2018

Are any of your classes repeat courses? *

Yes

No

Are any of your classes online? *

Yes

No

Do any of your classes fall outside your degree plan but are pre-requisites for future courses? *

Yes

No

Is this your graduating semester? *

Yes

No

Is this a change of Major from the last certification? *

Yes

No

Have you changed your Major with registration? *

Yes

No

N/A

Will you be receiving any scholarships or tuition waivers for this semester?

Yes

No

What Chapter of GI Bill will you be using?

Chapter 33 Post 9/11

Chapter 33 TOE (dependent transfer of entitlement)

Chapter 30 Montgomery GI Bill (Active Duty)

Chapter 31 Vocational Rehab

Chapter 35 Dependent Education Assistance (DEA)

Chapter 1606 Montgomery GI Bill (Reserve/National Guard)

FTA only

Other

I don’t know

Will you be using Pell grants or loans and will you need dispersment of these monies on day 1 of school due to financial hardship?

Yes

No

Major changes must use the Major Change Form and submit to registration for processing.

What degree are you seeking? *

Comments

By submitting this form, I acknowledge the following:

1. I am responsible for the payment of my tuition and fees regardless of VA benefits received.
2. The only registered classes that can be certified are those that fall within my degree plan.
3. It is my responsibility to notify the Veterans Coordinator if I add or drop a class. (including block classes)
4. Classes can be purged for non-payment of tuition if I have an outstanding balance with Dixie State University

Acceptance *

I accept the above statement