This form must be completed every academic year. Fields marked with an * are required.

Read each section carefully - an incomplete or incorrect submission will result in delays. All communication from the Registrar's Office will be sent to the student's official Clarke email account.

Student Information

Email Address*

First Name*

Last Name*

Phone*

Mailing Address*

Country

Street

City

Region

Postal Code

Relationship to Veteran*

If self, what branch of service?

If self, are you currently on active duty?

Yes

No

Have you received education benefits at Clarke before?*

Yes

No

Have you utilized education benefits at a previous institution?*

Yes

No

You must complete VA Form 22-1995 Change of Program on the VONAPP.

Enrollment

Please indicate which semester(s) this form is to be applied to:

Fall

Spring

Summer

Semester Year

What is your current class level?

What is your major program of study?

Military Education Benefit

Indicate your Military Education Benefit category (please submit certificate of eligibility using the uploader at the bottom of this section, or email it to registrar@clarke.edu.)

Post 9/11 GI Bill (Chapter 33) aka Yellow Ribbon eligible?

Yes

No

Montgomery GI Bill - Active Duty (Chapter 30)?

Yes

No

Montgomery GI Bill - Reserve Duty (Chapter 1606)?

Yes

No

Reserve Educational Assistance Program (Chapter 1607)?

Yes

No

Survivors and Dependents Educational Assistance Program (Chapter 35)?

Yes

No

Please provide the Name and Social Security Number of the parent providing the military benefits.

Parent First

Parent Last

We are committed to protecting you privacy.

Our databases are actively monitored and are firewalled to ensure the protection of your personal information, and we employ all industry-standard safeguards.

Social Security Number

Vocational Rehabilitation (Chapter 31)?

Yes

No

DoD - Federal Tuition Assistance?

Yes

No

National Guard Member?

Yes

No

Upload your Certificate of Eligibility here.

Agreement and Signature

YOU MUST NOTIFY OUR OFFICE of: (a) Any change in your schedule, (b) any changes in your program, or (c) withdrawal, dismissal or activation. By Signing below, you are accepting responsibility for any overpayment resulting from inaccurate or false information. You have the legal responsibility of notifying the Clarke University Registrar's Office of any changes in status or enrollment. Failure to notify this office of any status changes may result in over/under payment and/or delay in receiving your Department of Veteran Affairs Educational benefits.

Note: VA will correct overpayments by subtracting the amount in question from subsequent payments.

Student Signature*

Click to Sign...

Date*

Military Education Benefit Enrollment

Student Information

Enrollment

Military Education Benefit

Agreement and Signature