University of Arkansas at Little Rock
Certification Request Form

Items marked with * are required


By submitting my UALR VA Certification Request form, I confirm that I have read and understand the following:

I understand the UALR VA office will certify my registration and ensure my class selections will not be deleted.
I authorize the UALR VA office to certify enrollment information to the Veterans Regional Office.
I understand the UALR VA office has to report dropped classes, term withdrawals, incomplete grades, non-developmental NC(No Credit) grades, and non-attendance grades to the Veterans Regional Office which may result in an overpayment.
I understand I have made a contractual financial obligation to pay all tuition and fees associated with any classes in which I register, unless I withdraw by the deadlines listed here. "Not Attending" does not remove this obligation.
    Summer 1: June 4, 2012
    Summer 2: May 30, 2012
    Summer 4: July 6, 2012

    Fall: August 29, 2012

UALR's official method of correspondence with students, including billings, is via the UALR assigned email address. I accept my responsibility to access my UALR assigned email account regularly and to take any required action.
I authorize UALR to apply any veteran educational benefits I receive toward my account balance. If my educational benefit is reduced or canceled, I understand that I will be fully responsible for all charges and should immediately contact the Student Accounts Office.
I understand that UALR will assess financial penalties on any past-due accounts. At semester end, I understand that if I have a past-due account, my account will be referred to an outside collection agency and result in additional charges.
I am responsible for reading and understanding the current Drop/Withdrawal refund policy of the University as it appears on the Bursar's website, www.ualr.edu/bursar .
I understand I must enroll in classes required for my degree/major.


Please select one of these options: This submission is
Initial submission of form for term
Update - due to change in enrollment for term
Student Information Last 4 digits of SSN:*
Last Name:*     First Name:*
Middle Initial:*
Date of birth* :
Email:* (UALR's official method of correspondence, including billings, is via the UALR assigned email address.)
Address:*     Apt:
City:*     State:*     Zip:*
Phone:*
Alternate Phone:
Program Information
Select your classification*
Undergraduate Post-Baccalaureate Graduate Doctoral

I have been accepted in the following degree program at UALR, if not accepted into a degree program choose Undeclared.
Select one*
in * (list anticipated major if undeclared)
Benefit Status* Are you on Active duty? Yes    No
Will you attend classes at another school this semester? Yes    No
Chapter 30 (Montgomery GI Bill)
Chapter 1606 (Selected Reserve/National Guard)
Chapter 1607 (Reserv Ed. Assistance Program)
Chapter 31 (Vocational Rehabilitation and Employment)
      Who is your Voc Rehab Counselor:
Chapter 35 (Dep/Surv. Education Assistance)
      VA File number:
Chapter 33 (Post 9/11 GI Bill)
       Veteran Spouse/Dependent    Percentage: %
      Will you receive other tuition assistance for this semester (TA, employee discounts, etc)?Yes    No
      Are you a resident of Arkansas?Yes    No
      Do you live in the UALR residence hall?Yes    No
Courses for Certification Semester*
Fall 2012 (August 23 - December 10, 2012) - Submit on or after July 1, 2012
Spring 2012- (January 17 - May 7 2012)
Summer 1 2012 (May 29 - August 7, 2012) - Submit after you finalize registration.
Summer 2 2012 (May 29 - July 2, 2012) - Submit after you finalize registration.
Summer 4 2012 (July 5 - August 8, 2012) - Submit after you finalize registration.

Year:* 20
Courses*
CRN # Course (e.g. - HIST 1311)

Total hours enrolled:*
Total hours to certify:*
Form Submission In order to receive VA benefits, students must be admitted as a degree-seeking student. By submitting this form, I agree to notify the UALR Office of Veterans Affairs should I change my major or adjust my schedule. Schedule changes may result in an overpayment. Submission of this form indicates that I have provided accurate information and agree to comply with all Veterans Regional Office Guidelines.