Student Number:
VA File Number (Chapter 35 Only):

Name:
Address:
City/State/Zip:
Phone:(123-456-7890)
Email Address:

NEW ADDRESSYES NO

Degree Sought:
Major:
Total Credits Earned to Date:

Summer I Number of Credits:
Summer II Number of Credits:
Remember: 4 Credits is full-time status and you must take 4 credits per session.

Please check one of the following listed below.

Montgomery GI Bill (Chapter 30): Active Duty Educational Assistance Program
Vocational Rehab (Chapter 31)
VEAP (Chapter 32): Contributory VEAP Service beginning on or after 1/1/77 through 6/30/85
Dependents (Chapter 35): Survivors' and Dependents' Educational Assistance
Montgomery GI Bill (Chapter 1606): Selected Reserve Education Assistance Program
Montgomery GI Bill (Chapter 1607): Selected Reserve Education Assistance Program

Advanced PaymentYES NO
(Form must be received by VA at least 30 days before the beginning of the term)

NOTE: You must notify Veterans Affairs if you change your credit status (increase or decrease) and if you plan on attending summer session.

If you have never received VA benefits through MSU Moorhead you must stop in this office as soon as possible after completing this form to be sure ALL paperwork is in order.