(Example of information needed.)
Application for Licensing and Certification Testing Fee Reimbursement

First -- Middle -- Last Name of Applicant

 

Social Security No.:

VA File No. (If Different):

(For Proper Payment Of Benefits Dependents Must Use VA File No.)

Mailing Address

 

 

Home Telephone No. (Include Area Code)

 

Work Telephone No. (Include Area Code)

 

Have you applied for VA Benefits before? o Yes o No

If no, please also complete VA form 22-1990 (Veteran) or VA form 22-5490 (Dependent) and submit it with this application.

To request a copy of either form, call 1-888-442-4551.

Name of Test

 

Name of Certification

 

Name and Address of Organization Issuing License

Date Test Taken:

 

Cost of Test:
 

I hereby authorize the release of my test information to the Department of Veterans Affairs.

Date Signed

 

Signature of Applicant (Do Not Print)

 

Please return this form and a copy of your test results to the VA Office which handles your area. The list of VA Offices follows.

 

 

 

Eastern Region

VA Regional Office
P.O. Box 4616
Buffalo, NY
14240-4616
Connecticut Massachusetts Pennsylvania
Delaware New Hampshire Rhode Island
District of Columbia New Jersey Vermont
Maine New York Virginia
Maryland Ohio West Virginia

 

Southern Region

VA Regional Office
P.O. Box 100022
Decatur, GA
30031-7022

 Alabama Mississippi South Carolina
Florida North Carolina Tennessee
Georgia Puerto Rico U. S. Virgin Islands
 

Central Region

VA Regional Office
P.O. Box 66830
St. Louis, MO
63166-6830

 Colorado Michigan South Dakota
Illinois Minnesota Tennessee
Indiana Missouri Wisconsin
Iowa Montana Wyoming
Kansas Nebraska  
Kentucky North Dakota
 

Western Region

VA Regional Office
P.O. Box 8888
Muskogee, OK
74402-8888

 Alaska Idaho Oregon
Arizona Louisiana Philippines
Arkansas New Mexico Texas
California Nevada Utah
Hawaii Oklahoma Washington

Training Outside the 50 States or the District of Columbia

If you’re training in Puerto Rico or the U. S. Virgin Islands, your claim will be handled by the Atlanta Regional Office (in Decatur, GA).

If you’re training in the Republic of the Philippines, American Samoa, Guam, Midway, Wake Island, any of the islands in the Federated States of the Marshall Islands, the Republic of Micronesia, or the Republic of Palau, your claim will be handled by the Muskogee, OK Regional Office.

If you’re training in any other foreign country or area, your claim will be handled by the Buffalo, NY Regional Office.