*Your Full Name:
Last four digits of SSN
*Date of Birth (mm/dd/yyyy):
*Street Address:
*City:
*State:
*Zip:
*Your E-Mail:
*Home Phone:
Work Phone:
Benefit Program	CH 30 MGIB - Active Duty CH 31 Voc Rehab CH 32 VEAP CH 35 Survivors & Dependants CH 1606 MGIB - Selected Reserve
Term	Summer Fall Spring 2004 2005 2006
Number of hours enrolled this term
Major
Comments
Today's Date:	Saturday, May 17, 2008