VA REGISTRATION / CERTIFICATION FORM Legal Name* First Last Email* Enter Email Confirm Email Veteran Educational Benefit*select one Chapter 30 Montgomery GI Bill Chapter 31 Vocational Rehabilitation Chapter 33 Post 9/11 Chapter 35 Survivor's and Dependents Chapter 1606 Selected Reserve Chatper 1607 REAP Other Academic Semester/Year*Fall 2018Spring 2019Summer 2019Total Number of Credits to be certified:*Please enter a number from 1 to 25.Student Certification I request to be certified for veteran education benefits during the semester listed above. I agree to the YACPA policies and procedures and grant permission to YACPA to release information concerning my educational records to the U.S. Department of Veteran Affairs. In addition, my address listed above will be updated in the California Veteran Affairs Agency database. I understand: I must update the College and VA Certifying Official if I adjust my schedule and/or change my program of study. I may be required to pay back funds to the VA for non-completed coursework or other non-allowable actions. I am responsible for paying my student account balance at YACPA.