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  1. Complete this form each semester for which you enroll and want to be paid.
  2. Courses previously completed and passed cannot be re-certified for payment.
  3. It is your responsibility to report class changes or withdrawals to the certifying official and the VA as they occur.
  4. Any classes listed on this form for payment must be degree applicable and listed on your student education plan provided by an Academic Counselor!

Term of Certification:
Guest Student:
Home Campus:
Your Name:
(Enter your full name)
Student ID or SSN:
Phone Number:
E-mail Address:
VA File Number:
(Dependent/Spouse please list SSN of Veteran)
VA Chapter Code:
New Major:
Course Name (i.e. ENGL) Course Number (i.e. 1500) Units Start Date(MM/DD/YYYY) ex: 3/19/2008 End Date(MM/DD/YYYY) ex: 3/19/2008 Add Drop
Agreement Terms
I certify that to the best of my knowledge the above information to be true and correct and that I am not duplicating courses I have successfully completed. I accept full responsibility to notify the certifying official and the VA of any changes in my enrollment effective upon the changes. I also understand that I may have to pay back the Department of Veteran’s Affairs if any overpayment is made to me.