VA Benefits Enrollment Reporting Request Form

By submitting this VA benefits enrollment request I am acknowledging that only classes required for my declared Clark State degree program(s) will be reported for my education benefits to the VA. My benefits will be based on the credit hours taken in required classes and the actual dates of enrollment.

I understand that if I add or withdraw from a class(es) after submitting this request it is my responsibility to notify the VA School Certifying Official by submitting an updated request.

I further acknowledge that if I fail to immediately notify the School Certifying Official when my schedule changes, I withdraw from a class and/or I stop attending a class, I may incur a debt with the VA for unearned benefits and/or with Clark State for unpaid tuition and fees.

Consent for storing submitted data * Yes, I give permission to store and process my data