Enrollment Certification Request Online Form

 You are using which of the following benefits:

 

Choose One::

  This is my initial enrollment certification request          
I have made changes to my enrollment (added or dropped classes since my initial request)

 Name:

 

Student ID:

 

  Phone Number:

 

  Has your phone number changed since your last term of enrollment?

  Yes No

Address:

 

City:
Zip Code:

  State:

  Has your address changed since your last term of enrollment?

  Yes No

Active E-mail Address:

 

Select one:

  Bachelor of Science Bachelor of Arts Masters

Major:

 

Teacher Certification:

  Yes No
   
  UT Tyler Enrollment Information

Semester Requesting Certification:

 
Courses in which you are enrolled during the term listed above:
 

  Are any of the courses listed above a repeat course?

  Yes No
If yes, please indicate which one(s):
 

  Are any of the courses listed above an internship or independent study?

  Yes No
If yes, please indicate which one(s):
 
   

Concurrent Enrollment Information

School:

 
Courses in which you are enrolled:
 

 The courses in which I am enrolled are required as a part of my current degree plan.

  Yes No
If no, please indicate which one(s):
 
 

I understand that dropping a course and/or completely withdrawing from the university may constitute an overpayment of benefits by the V.A. and that I will be responsible for returning these funds to the V.A.. Additionally, it is my understanding that if I drop a course at any time during the semester, it is imperative that I notify the V.A.. Certifying Official via telephone, e-mail, or in person. Failure to do so may prohibit me from using VA benefits in the future. Submitting and dating this form indicates my understanding of and agreement with the above statement.

Date: