Military/Veteran Request for Benefits Information Form

• *First Name:
• *Last Name:
• *E-mail:
• *Phone Number:
• *Student ID: (if known)
•  
• *Campus Location:    
  
  Clinton Community College
  Muscatine Community College
  Scott Community College
  
•  
• *Status:
  
  Veteran
  Active Duty
  National Guard
  Reserve
  Family Member
  
• *Are you a Guest student at our institution?
  
  Yes   No
•  
• *Military benefits you will be using: (Mark all that apply)
  

  	VA educational benefits
  	Federal Tuition Assistance
  	Iowa National Guard Scholarship
  	Unsure

• *If you are using VA educational benefits, have you used it previously at another institution?
  
  Yes   No
• *If eligible for VA educational benefits, which Chapter will you be using?
  
  Chapter 30 (Montgomery VA educational benefits for Active Duty)
  Chapter 31 (Vocational Rehabilitation)
  Chapter 33 (Post 9/11)
  Chapter 35 (Dependents Educational Assistance)
  Chapter 1606 (Reservists Montgomery VA educational benefits)
  Unsure
  

It is the policy of Eastern Iowa Community College District not to discriminate in its programs, activities, or employment on the basis of race, color, national origin, sex, disability, age, sexual orientation, gender identity, creed, religion, and actual or potential family, parental or marital status, as required by the Iowa Code §§216.6 and 216.9, Titles VI and VII of the Civil Rights Act of 1964 (42 U.S.C. §§ 2000d and 2000e), the Equal Pay Act of 1973 (29 U.S.C. § 206, et seq.), Title IX (Educational Amendments, 20 U.S.C. §§ 1681-1688), Section 504 (Rehabilitation Act of 1973, 29 U.S.C. § 794), and Title II of the Americans with Disabilities Act (42 U.S.C. § 12101, et seq.).

If you have questions or complaints related to compliance with this policy, please contact EICC’s Equal Employment Opportunity Officer/Equity Coordinator, Eastern Iowa Community College District, 101 West Third Street, Davenport, Iowa 52801, 563-336-5222, equity@eicc.edu or the Director of the Office for Civil Rights U.S. Department of Education, John C. Kluczynski Federal Building, 230 S. Dearborn Street, 37th Floor, Chicago, IL 60604-7204, Telephone: (312) 730-1560 Facsimile: (312) 730- 1576, TDD (800) 877-8339 OCR.Chicago@ed.gov.