Office of Admissions & Recruitment
8470 North Overfield Road
Coolidge, AZ 85128
Telephone: 520-494-5402 Fax: 520-494-5083
Email: veterans@centralaz.edu
Website: www.centralaz.edu/va
CAC VA CERTIFICATION REQUEST FORM
This form must be completed each semester or summer session that a student plans to request VA Education Benefits.
Students must be enrolled in classes at Central Arizona College.
STUDENT INFORMATION
880Legal Name (Last, First, Middle)
Current Address
CAC Student ID #
City
(Area Code) Telephone Number: _______________________
State
Zip Code
CAC E-Mail Address: ______________________________________________
*NOTE: CAC VA listserv or VAOnce notifications sent via CAC email account
Select Benefit:
□ Chapter 30 Montgomery GI Bill □ Chapter 31 Vocational Rehabilitation
□ Chapter 33 (Veteran) Post 9/11 Eligibility % ______
□ Chapter 33 (Spouse/Dependent) Post 9/11 Eligibility % ______
□ Chapter 35 DEA VA File #_____________________________
□ Chapter 1606 Reserves/National Guard □ Chapter 1607 REAP
(1)
□
□
□
Have VA Benefits been used within the past year at CAC?
Yes - Proceed to question #2.
No, but have applied but not received notification for education benefits from the VA. DATE: __________________
No, but received notification for education benefits from the VA and submitted to CAC School Certifying Official? DATE: ___________________
(2) Have you attended another higher education institution? □ No □ Yes If yes, list below:
1) ____________________________________________________________________ Transcripts Submitted □ Yes □ No
2) ____________________________________________________________________ Transcripts Submitted □ Yes □ No
3) _____________________________________________________________________ Transcripts Submitted □ Yes □ No
NOTE: Failure to disclose previous college(s) is a violation of the Student Code of Conduct and is grounds for denial of admissions or immediate
suspension if enrolled.
Are you receiving outside funding for tuition purposes other than Financial Aid? If yes, what specific type: ____________________________________
The VA requires that all outside funding paying for tuition and fees be reported to them e.g. scholarship, military or employer tuition assistance, or
tuition waiver.
Are you a seeking to be a Guest Student? □ No □ Yes- Please have your Parent School Certifying Official (SCO) send a parent letter.
Indicate the name of the school and contact information for the Parent SCO:
School: ______________________________________________________________________
Contact Person: _______________________________________________________________ Phone Number: __________________________
CERTIFICATION INFORMATION: Must meet with Academic Advisor for POS or MAP applicability (signature required)
Semester and year you would like to be certified for (select one semester and specify year):
□ Fall ____ □ Spring _____ □ Summer I ______ □ Summer II ______ Total Credit Hours ______
Are you graduating this upcoming semester? □ No □ Yes.
*Attach a copy of your current schedule of classes. (Schedule is required for Certification to be completed)
Program of Study (See Back), Specific Area: _________________________________e.g. 1370- Sports Management.
Do not leave POS area blank, otherwise certification will not be processed. *Check with Registration Office to see if Program of Study is correct on
Student Account. If incorrect, please update records.
PROGRAM OF STUDY- DEGREES AND CERTIFICATES
Associate of Arts (AA)
1421
0007
1377
1376
0001
Administration of Justice Studies
Agriculture
Athletic Studies
Fine Arts
Liberal Studies
Associate of Arts –
Elementary Education (AAEE)
1418 Elementary Education
Associate of Business (AB)
0001 Liberal Studies
Associate of Science (AS)
0007
1380
1401
0017
1201
0001
Agriculture
Biotechnology
Chemistry
Community Public Health
Geology and Planetary Science
Liberal Studies
Associate of General Studies (AGS)
0002 General Studies
1330 Pre-Nursing
Associate of Applied Science
(AAS)
1110 Accounting
1421 Administration of Justice
1500 Agriculture, General
0021 Artist & Venue Mgt
1120 Business
1130 Computer Programming
1495 Corrections
1229 Culinary Arts
1517 Diesel/Heavy Equip. Tech.
1310 Dietetic Technician
1303 ECE Family Child Care
1305 ECE Infant/Toddler
1306 ECE Management
1302 ECE Preschool
0016 Equine Mgt Training
1362 Fire Science Technology
0031 Geographic Information Syst
1334 Graphic Design
1367 Health Information Tech.
1514 Heavy Equipment Operator
1140 Hotel/Restaurant Mgt.
1535 John Deere Construction
1149 Live Audio & Lighting
1499 Manufacturing Engineering
1363 Massage Therapy
1357 Medical Assistant
1131 Microcomputer Bus. App.
1498 Nanofabrication Technology
0027 Network Systems Admin
1333 Nursing (for accepted applicants
1339
0019
0024
1208
only. All others, use Pre-Nursing)
Paramedicine
Popular Music Perform.
Renewable Energy Tech
Welding Tech
Associate of Applied Science (AAS)
(cont.)
0013
Radiologic Tech (for accepted
applicants only. All others, use AGS)
0020
1370
Recording Engineering
Sports Management
Certificate Programs
000A
000B
000S
1110
1421
1496
1502
1500
1127
0021
0029
1542
0022
1120
1324
0018
1128
1309
1518
1129
1130
1378
1543
1174
1175
1307
1517
AGEC – Arts
AGEC – Business
AGEC – Science
Accounting
Administration of Justice
Advanced Corrections
Agriculture Business
Agriculture, General
Application Dev/Web Design
Artist & Venue Mgt
Baking and Pastry
Basic EMT
Biofuels Technician
Business
Clinical Lab Assistant
Comm. Skills for the Profess.
Communication Studies
Community Nutrition Worker
Computer Aided Design
Computer Appl. for Bus. Users
Computer Programming
Coding and Reimbursement
Critical Care for Paramedics
Culinary Arts I
Culinary Arts II
Diabetes Care and Education
Diesel/Heavy Equip. Tech.
Certificate Programs (cont.)
1323
1205
1303
1305
1306
1302
0016
1504
1206
0030
0028
1364
1540
1514
1140
1207
1505
1149
1151
1527
1363
1113
1131
1125
1325
1536
1114
0019
1331
0020
1373
1374
0023
1525
1115
Dietary Manager Training Prog.
Driver Operator
ECE Family Child Care
ECE Infant/Toddler
ECE Management
ECE Preschool
Equine Mgt Training
Field Programmable Gate Array
Fire Officer I
Firefighter Operations
GIS Drafting and Mapping
Group Fitness Instructor
HE Mechanics App. Prog./AGC
Heavy Equipment Operator
Hotel/Restaurant Mgt
Human Performance
LabVIEW Programming
Live Audio & Lighting
Management
Manufacturing Electronics
Massage Therapy
Medical Assistant
Micro. Bus. App. Specialist
Network Administration
Nutrition and Health Promotion
Operator App. Program/AGC
Pharmacy Technician
Popular Music Perform.
Practical Nursing
Recording Engineering
Recreation Management
Sports Information
Solar Photo Voltaic Tech
Welding
Wildland Firefighter I
TERMS & CONDITIONS AND STUDENT ACKNOWLEDGEMENT
Students may be eligible to receive education benefits if they are registered in courses that apply to the student's approved program of study.
Students applying for veteran's education benefits should allow eight to ten weeks before receiving benefits. The amount of benefits awarded is
determined by the Department of Veterans Affairs and is based on the number of credit hours for which a student is enrolled and the length of the
enrollment period for each course. Students will inform the School Certifying Official (SCO) if any changes in schedule of classes occurs. Submit the
CAC Certification Form to the SCO every semester to use VA education benefits. Submit all prior college and military transcripts to SCO and Transcript
Evaluation Office. Failure to comply will result of volition of Student Code of Conduct, and non-processing of certification paperwork by SCO. Once
transcript evaluation is complete, I understand that there may be prior credit applicable to the Program of Study for a course taken, and I would be
responsible for paying back funds to VA if course was initially certified by SCO. Students must meet with Academic Advisor to ensure courses are
applicable to Program of Study and provide SCO with POS or Master Academic Plan (MAP). This may involve regularly reviewing degree requirement
with Advisor. Notify Registration Office and SCO of a Change of Program if student decides to change Program of Study (POS) and meet with
Academic Advisor for a MAP. Report attendance, if required by the VA education benefit e.g. CH. 1606, 1607, & 30. Payment for courses not
applicable to Program of Study is student’s responsibility. Short-term (also called late start, compressed, accelerated pace) courses will affect
benefits, especially full-time status. Maintaining Satisfactory Academic Progress (SAP) is required for continued use of VA education benefits; failure
to do so, may result in suspension or termination of VA Educational Benefits. Notifying the SCO of withdraw from a course, and possible student
responsibility to pay back funds to the VA. In the event of a deployment or hardship that requires the student to completely withdraw from CAC
may require supporting documentation to be submitted to CAC SCO.
By signing below, you are authorizing Central Arizona College’s VA School Certifying Official (SCO) to submit and certify courses above for the listed
semester. You further agree to acknowledge that you are responsible for the above terms and conditions and hereby declare that I have read and
understood the Terms above and failure to comply with these terms may result in lack/loss/delay of VA Education Benefit payment, debt to the
College, and/or debt to the Department of Veteran Affairs.
Student Signature (Abode EchoSign or any other Electronic Signature accepted)
Date
--Office use only--
VC Code: Yes or No
Confirmed: Yes or No
VA Code: Yes or No
Certified Date: