If you have any questions please email firstname.lastname@example.org or call 515-271-1460. Please complete this form following course registration for each term (Fall, Spring or Summer, and Year). This form must be submitted in order for the Office of the Registrar to verify your enrollment with the VA. To apply for or manage education benefits, please visit https://www.vets.gov/education/apply-for-education-benefits/. Student InformationName* First Last VA File Number*Payee Number (Ch. 35 only)Current Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanÅland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarrussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRéunionRomaniaRussiaRwandaSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUS Minor Outlying IslandsUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabwe Country Email* Primary Phone*Academic Program/ Degree Sought*Anticipated Completion YearTerm Requested for VA Benefits*Are you repeating any courses for the term indicated?*YesNoIf yes, which course(s)?*Are you receiving any additional military tuition assistance?*YesNoBenefit InformationMilitary Status*Active DutyVeteranNational Guard/ReservistDependentSpouseMilitary Branch*Is this your first time using military benefits at any institution?*YesNoIf this is the first you are using benefits, you must apply for benefits using VONAPP (VA Form 22-1990) at http://vabenefits.vba.va.gov/vonapp/default.asp.Is this your first time using military benefits at DMU?*YesNoIf this is the first time you are using your benefits at DMU, please submit your Certificate of Eligibility to The Office of the Registrar before your enrollment certification can be submitted to the VAHave you used educational benefits at another institution?*YesNoIf yes, please submit a Change of Program or Place of Training form (VA Form 22-1995) using VONAPP at http://vabenefits.vba.va.gov/vonapp/default.asp before completing this form.Please indicate your VA Education Benefit, as applied on VA Form 22-1990*Chapter 33 – Post 9/11 BillChapter 30 – Montgomery GI Bill for Active DutyChapter 35 – Survivors’ and Dependents Assistance-DEAChapter 31 – Vocational RehabilitationChapter 32 – Veterans Educational Assistance Program (VEAP)Chapter 1606 – Montgomery GI Bill for Select ReserveChapter 1607 – Reserve Educational Assistance Program (REAP)Additional Requirements The Department of Veterans Affairs (VA) requires an enrollment certification for every term you are enrolled. You must submit this form to the Office of the Registrar each term you wish to receive benefits. If you have not done so already, please request your official military transcript be sent to the Office of the Registrar. Only courses that meet degree requirements for the program in which you are enrolled are eligible. If you add or drop a course, withdraw from a course, submit a leave of absence request, or receive an incomplete (I) course grade, please contact the Office of the Registrar. Your benefits may be adjusted based upon the change in your status. You will need to contact the Accounting Office at StudentAR@dmu.edu or 515-271-1473 to determine if repayment of benefits is required. You must notify DMU if your benefits are denied, revoked or exhausted. For information regarding your payment status, please call the VA directly at 1-800-827-1000. Please Read the Following Important Information If you are receiving Chapter 30, 1606 or 1607 benefits you are required to certify your attendance each month with the VA. You verify your attendance via the W.A.V.E. (Web Automated Verification of Enrollment). You can access the WAVE system through the GI Bill Home page at www.gibill.va.gov. If you also plan to receive additional DOD benefits, including Military Tuition Assistance, contact the Office of the Registrar as this may be considered a Duplication of Federal Benefits and is prohibited by law.Student Certification*I have read and understand all requirements and information on this form. I understand that this form must be submitted each term after registering for courses. I will immediately report any changes in enrollment status or an incomplete grade (I) to the Office of the Registrar. I am aware that any change in my enrollment status could alter my benefits and may result in repayment to the VA and/or to Des Moines University. I Agree This iframe contains the logic required to handle Ajax powered Gravity Forms.