Request for VA Benefits Form 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* First Last Email* To ensure that your request is submitted properly, please use your UMW email address.Banner ID:*Last 4 SSN*Address Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Status: Active Duty Veteran Dependent Benefits Chapter 30 – MGIB Chapter 31 – Veteran Readiness and Employment Chapter 33 – Post 9/11 Chapter 35 – DEA Program 1606 – Selected Reserve Other Federal Funding or Tuition Scholarship Yes No If Yes, What Type? VMSDEP MyCAA TA Other If Other, List:UMW Status: Continuing Student First Time/New Student¹ Guest Student¹ 1If you are a new or guest student, please provide UMW with the Certificate of Eligibility. You can upload the certificate or send it to the School Certifying Official (SCO) via email or fax or hand-deliver it to Lee Hall, 2nd Floor, Fredericksburg Campus. Ryan Hastings is the School Certifying Official for BLS, BSN, certificate students, graduate students using VA education benefits, and any student participating in the Chapter 31 Veteran Readiness and Employment program or using Chapter 1606—Selected Reserve benefits. His contact information is rhasting@umw.edu or 540-654-5853. Patricia Sarkuti is the contact for undergraduate BA/BS students utilizing veteran benefits, except for the Chapter 31 Veterans Readiness and Employment program. Her contact information is psarkuti@umw.edu, phone: 540-654-2140. Upload VA Certificate of EligibilityMax. file size: 5 MB. Program of Studies:* BA BS BSN BLS MED MBA MSGA Certificate Non-Degree Required FieldSemester to Certify*Please choose a SemesterSpringSummerFallYear*Please choose a Year202620252024Comments: Δ