Steps to filling and saving form: 

1. Start by clicking the box for the 800 number under Student Information and 

begin to fill out information.  

2. Use the “Tab Button” to go through the document to prevent missing 

information. If you fail to fill out a box that is applicable to you, then the 

form will be sent back to you.  

3. The “Tab” option will not tab you to the second page. After completing the 

first page, scroll to the second page and place the cursor in the first box at 

the top. Resume using the “Tab Button”. 

4. The VA has given permission to accept electronic signatures, so any box 

that requires a signature or initials, please type it in. You DO NOT need to 

physically print the form out and sign it.  

5. After you have completed the form you will need to save the information in 

a PDF form. Go to the printing options and choose the PDF printer. This will 

allow you to save it to your Desktop as a PDF document. Attach the 

document to an email and send it to the School Certifying Official (SCO). 

DO NOT use “Save As”. This will only download a blank form to your 

desktop, even after you have filled it out.  You will need to use the PDF 

printer.  

NOTE: If you choose to physically print the form out to sign it, or for any other 

reason, please note you will have to scan it back into a PDF document and email it 

to the SCO. School campuses are closed, so assistant in scanning documents will 

not be available. Please do not use your phone to scan documents in.  

Please see CAC VA Website for all contact information and forms.  

Received On: VA Prom Note: First Semester:

Received By: VA Map Hold: New or Transfer:

For Official Staff Use Only

Purpose: To obtain information pertaining to NEW veterans or dependents intending to use VA Education Benefits and

correctly input data into the necessary systems for academic registration, VA certification, and military reporting.

NEW - VA Education Benefits’ Admission Form

Applicant Information:

CAC Student ID #880-__________ - __________ Social Security # _________________________________

First Name: _________________________ Middle Initial ____ Last Name: _________________________

Phone Number: ___________________ DOB: ____________ Branch of Service: _____________ or NA (dependents)

Home Address: ____________________________________________________________

City: ________________________________ State: _______ Zip Code: ______________

CAC Email Address: _________________________________________________________

Secondary Email Address: ____________________________________________________

VA Education Benefits:

Select the Chapter Benefit you are using:

CH 33 POST 9/11 at ______% I am a: Veteran ____ SPOUSE ____ CHILD____

CH 35 Dependent and Survivor's Assistance (DEA) ____ I am a: SPOUSE ____ CHILD ____

CH 35 VA FILE# ___________________________ CH 35 Payee # _____

CH31 Vocational Rehabilitation ____

CH 30 Montgomery ____

CH 1606 Selected Reserve/Guard ____ CH1607 Reserve Educational Assistance (REAP) ____

Date applied for Benefits/Update Change Benefit through Vets.gov: ____________

I have received my Certificate of Eligibility (COE): Yes ____ No ____

Creation and responsibility for form and information obtained:

Military/Veteran Services Department Signal Peak Campus, 8740 N. Overfield Road Coolidge, AZ 85128 Phone: 520-494-5517 Veteran Education Benefits website www.centralaz.edu/va

PREVIOUS VERSIONS ARE OBSOLETE REVISED: 27 JAN 20

Transcripts- Military Training and Prior College:

Only veterans must submit official Military transcripts. Veterans and dependents must list and provide all prior colleges,

universities, trade schools, or post-secondary education institutions' official transcripts to CAC by your second semester or benefits

may be discontinued.

Name of School Requested Date Received Date Evaluation Date

**I certify that all institutions I have previously attended are listed above and I will request an official academic transcript to be sent to CAC

Admissions Department. A copy of the Joint Service Transcripts from the Military for my time of service will also be given to the SCO for VA

purposes. I understand failure to provide all official transcripts to CAC could result in an overpayment from the Department of Veterans

Affairs and/or cause an interruption of my VA Education benefits.**

Signature: ______________________________ Date: _________________

Semester Term:

____Spring (Jan – May) ____Summer (June – Aug) ____Fall (Aug – Dec) Year: 20______

VETERANS: List military/branch of service, (ex: USA, USMC, etc.), on the first line and all other colleges previously attended

where VA Education was used. Write “NONE” if no previous colleges, universities, trade schools etc., were attended.

Campus:

Please check the campus you plan to primarily attend and/or receive student service support from:

______ Signal Peak Campus _______ San Tan Campus ________ Aravaipa Campus

______Maricopa Campus _______ Superstition Mountain Campus

Degree or Certificate Program:

VA Education Benefits cover the cost of classes that apply to a specific program of study. By registering for classes that do not apply to

my program, courses will not be certified, therefore the cost (tuition and fees) are the responsibility of the student.

Check the degree or certificate below you plan to pursue: (T = Transfer degree to university)

___ AEE –AA in Elementary Edu (T) ___ ABUS Associate of Business (T) ___ AGS – Associate in General Stu (T)

___ AA –Associate of Arts (please list specific program , if applicable)______________________________________

___ AS – Associate in Science (please list specific program, if applicable)_______________________________________

___ AAS – Associate of Applied Sciences (please list specific program) ________________________________

___ Certificate (please list specific program) _____________________________________

PREVIOUS VERISONS ARE OBSOLETE REVISED: 27 JAN 2020

Official Use Only Official use Only