Current Start Confirm & Submit Complete Form 816 - VA Educational Benefits Request Student Information Name First Middle Last Suffix Mailing Info Address City/Town - Select -AlabamaAlaskaAmerican SamoaArizonaArkansasArmed Forces (Canada, Europe, Africa, or Middle EastArmed Forces AmericasArmed Forces PacificCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFederate States of MicronesiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarshall IslandsMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPalauPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirgin IslandsVirginiaWashingtonWest VirginiaWisconsinWyoming State/Province ZIP/Postal Code Email Address Date of Birth Last Four of Social Security # XXX-XX- Primary Telephone Secondary Telephone Curriculum / Academics Curriculum Title - Select -Accounting and FinanceAgricultural Systems TechnologyAir Conditioning, Heating, & Refrigeration TechnologyArchitectural TechnologyAssociate in ArtsAssociate in EngineeringAssociate in Fine Arts: Visual ArtAssociate in ScienceAutomotive Systems TechnologyBaking & Pastry ArtsBiopharmaceutical TechnologyBiotechnologyBuilding Automation TechnologyBusiness AdministrationBusiness AnalyticsCivil Engineering TechnologyCloud InfrastructureCollision Repair and Refinishing TechnologyComputed TomographyComputer Programming & DevelopmentConstruction Equipment Systems TechnologyConstruction Management TechnologyCosmetologyCriminal Justice & Forensic Science TechnologiesCulinary ArtsCybersecurityData Science and Programming Support ServicesDental AssistingDental HygieneDiesel and Heavy Equipment TechnologyEducationElectrical Systems TechnologyElectronics Engineering TechnologyEmergency Medical ScienceEsthetics TechnologyFacility Maintenance TechnologyGeomatics Technology (Surveying)Graphic DesignHealth and Fitness ScienceHeavy Equipment & Transport TechnologyHospitality ManagementHuman Services TechnologyInterior DesignIT Service and SupportMagnetic Resonance ImagingMammographyMechanical Engineering TechnologyMedical AssistingMedical Laboratory TechnologyMedical Office AdministrationNetworking TechnologyNeurodiagnostic TechnologyNursingOffice AdministrationParalegal TechnologyPharmacy TechnologyPlumbingPractical NursingPublic Safety AdministrationRadiographySimulation and Game DevelopmentSonographySupply Chain ManagementWeb & UX DesignWeb DeveloperWelding Technology Term Year Military Service VA File Number (For dependents only.) VA Eligibility Please check education benefit you are eligible for. Chapter 33: Post-9/11 Chapter 33: Post-9/11 - Transfer of Entitlement (TOE) Fry Scholarship Chapter 30: Montgomery GI Bill Chapter 31: VA Vocational Rehabilitation Chapter 35: Dependent/Survivor Assistance Chapter 1606: Selected Reserve/Guard Chapter 1607: REAP Tuition Assistance Will you receive Tuition Assistance from the military? Yes No Former/Present Military or Reserve Branch - Select -ArmyNavyAir ForceMarinesCoast Guard Currently on Active Duty? Yes No Discharge Date Indicate the date of your discharge. Payment Preferences Advance Payment Request Yes No Note: Advance payment is not an option for Post-9/11 GI Bill. ** Advance Payment requests must be submitted to the Military & Veteran Services Department at least six weeks before the start of the term. The VA reserves the right to reject any Advance Payment requests. Attest & Sign I acknowledge the information provided is accurate. Should any information change, I will notify the Military & Veterans Services Department in writing. I agree to adhere to policies and procedures set forth by both the U.S. Department of Veterans Affairs and Wake Technical Community College. Attestation & Signature I will comply with VA and college regulations regarding course drops and withdrawals and termination of registration. I understand, if applicable, I must verify attendance at the end of each month. I understand enrollment information will not be submitted to the VA until I am registered for courses. I understand I will not be paid for courses not in my curriculum. I understand I will not be paid for courses challenged or audited. I understand I will not be paid for remediation and academic support courses taught online. Signature Date
