Name: *

VA File Number: ss# *

Are you a Chapter 35? (see below for a definition) yes no 
  If yes, you must include Case File # *

Contact Information

Mailing Address *
Telephone number*
E-mail address*
City *State * Zip *

Have you previously applied to the VA for educational benefits?  Yes   No *

VA Chapter - 30  31  35  1606*
If you do not know what chapter you are/will be, click here.

Current Semester
I am currently enrolled in the semester.
The last semester I was certified to the VA was .
At DMACC:   Yes   No*  If other institution, where? *

Current Enrollment Information

Semester enrollment notification
I am/will be registered for the Fall Spring Summer semester for credit hours.

Drop/add credits - withdrawal from DMACC
I dropped added credit hours on (date).
I withdrew completely from classes on (date) .
I was dropped for non-payment on (date) .  I will reregister on .

Change of program
I have changed my program.  I am now enrolled in .
Please send me a VA Form 22-1995 - Required for Change of Program.
I have have not informed the VA of my address change.

Change of address
My new mailing address is:

City State Zip
Ihave have not informed the VA of my address change.
If not, click here and do so.

Deployment status
To read DMACC's procedures on deployed students, click here.
I received deployment orders on (date) .  They require me to report for duty on (date) . 
I am submitting a copy of my orders immediately to you by: bringing in person mailing sending by FAX sending by third party.
I understand you will process my "withdraw" status from both the college and the VA as soon as you receive orders.