Laney College Veteran Resource Center (VRC) Intake Form

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Please complete the questions below. We will contact you via email if any additional information is needed.

*At the time of submission of this form, you MUST email the following documentation:

1. A copy of your VA Letter Of Eligibility
2. A copy of your DD214

First Name *

Last Name *

Student ID Number *

Phone Number *

Email Address (all correspondents will be through this email address) *

Enrollment Status *

New Student/ Transfer

Returning Student

Continuing Student

I am applying for Veteran Benefits Under The Following Chapters *

Chapter 30. Montgomery Bill

Chapter 31. Vocational Readiness and Employment

Chapter 33. Post 911

Chapter 35. Survivors and Dependents

ACTION NEEDED: Please email a copy of your VA Letter Of Eligibility to jcarey@peralta.edu

ACTION NEEDED: Please email a copy of your DD214 to jcarey@peralta.edu

Are you an Out-Of-State Student? *

Yes

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