Veteran and Military Student Success
UNIVERSITY OF SOUTH CAROLINA AIKEN
STUDENT INTAKE FORM
Contact Information:

New Student

Current Student

Transient Student

Concurrent Student

Transfer Student
Date: _________________________
Starting Semester: ______________
Last Name: _________________________________ First Name: ____________________________ Middle Initial: ____
Sex:
Male
Female
DOB (Month/Day/Year): ______/_______/______
Address: ____________________________________________________ City: ____________________________
State: ____________ Zip Code: ______________________ County: _______________________________________
Primary Phone: ___________________________________
Other Phone: ________________________________
Personal Email: _______________________________________
USC ID: _______________________________
Military Information:
Status:
Service Member
Veteran
Military Family Member
The following questions pertain to Veterans or Service Members:
Service Component:
 Active Duty
 Selected Reserve
 National Guard
Service Branch:





Type of Discharge:
Army
Marine Corps
Navy
Air Force
Coast Guard
Rank: ____________________
Purple Heart Recipient? __ Yes __ No
Honorable
OTH
Dishonorable
Med Retired
Still Active
 Retired





Combat Deployed? __Yes __No
Dates of Service (Month/Year): ______________________________________________________________
Benefit(s) Eligible to Receive:
___ Montgomery (CH30)
___ Post 9/11 (CH 33)
___Montgomery Selected Reserve/Guard (CH 1606)
___ Voc Rehab (CH 31)
___ Dependent (CH35)
___ Free Tuition (South Carolina Governor’s Letter)
___ Tuition Assistance
___ Yellow Ribbon
CERTIFICATION REQUEST FORM:
If you are planning to use your VA Education Benefit, please fill out the following fields. Then read and sign the agreement below.
First time applicants applying under:

Chapters 30, 32, 33, 1606/1607, complete and submit: Certification sheet, VA form 22-1990; Certificate of Eligibility

Chapter 35, complete and submit: Certification sheet, VA 22-5490 (if transferability applies); Certificate of Eligibility

Chapter 31, complete and submit: Certification sheet. An authorization form from your case manager is also required.
Students transferring from another institution:

Chapters 30, 32, 33, 1606/1607, complete and submit: Certification sheet; VA form 22-1995; Certificate of Eligibility

Chapter 35, complete and submit: Certification sheet; VA form 22-5495; Certificate of Eligibility
Information Needed for VA Certification:
SSN: _____________________________________
File No (Ch. 35 Only): _________________________________
Entitlement and Semester Requested:
(Check the semester for which you are enrolled, the corresponding benefit and degree objective.)
Fall
Spring
Maymester
Summer I
Summer II
Degree/Major (e.g. B.S. Biology): _______________________________________________________________
Minor/Concentration: ________________________________________________________________________
Benefit Eligible to Receive:
Montgomery (CH30)
Dependent (CH35)
Post 9/11 GI Bill (CH 33)
Active Duty (T/A)
 Interested in Yellow Ribbon
Voc Rehab (CH 31)
Reserve/Guard (CH 1606/1607)
Free Tuition (South Carolina Governor’s Letter)
 Continuing Yellow Ribbon
Certification Agreement:
The information I have provided is true. I have been informed of the purpose and use to be made of the solicited
information and understand it will be used for processing my VA education benefits. I understand that:
1.) It is my responsibility to notify the USC Aiken Veteran and Military Student Success staff within five (5) business days
of any changes in my degree program or projected semester hours (drops/adds/withdrawals/major changes) by
providing an updated schedule and, if adding a class, an updated advisement form.
2.) I am only authorized to collect VA educational benefits for those courses and electives as indicated on my signed
advisement form, which are required for my degree as stated in the USC Undergraduate and Graduate Academic
Bulletin.
3.) The school will certify me to the VA only after I have completed/renewed this and other relevant forms.
Student Signature: ______________________________________________
Date: _______________