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U.S. DOD Form dod-va-22-1919 CONFLICTING INTERESTS CERTIFICATION FOR PROPRIETARY SCHOOLS ONLY 1. NAME AND ADDRESS OF INSTITUTION PURPOSE This form informs individuals that the law has restrictions concerning any potential conflict of interests. I agree to immediately notify VA of any potential violations of the above prohibitions. SIGNATURE OF PRESIDENT OR CHIEF ADMINISTRATIVE OFFICIAL OR SCHOOL VA FORM JUL 1995 22-1919 TITLE EXISTING STOCKS OF VA FORM 22-1919 MAY 1991 WILL BE USED. See certifications 1 and 2 below. These certifications not only apply to chapters 31 and 36 of Title 38 U*S*C. but also apply to the following programs administered by the Department of Veterans Affairs VA MGIB Montgomery GI Bill-Active Duty Educational Assistance Program Chapter 30 of Title 38 U*S*Code VEAP Veterans Educational Assistance Program Chapter 32 of Title 38 U*S*Code DEA Dependents Educational Assistance Chapter 35 of Title 38 U*S*Code MGIB-SR EAPP Educational Assistance Pilot Program Section 903 of Public Law 96-342 1 PROPRIETARY PROFIT SCHOOLS ONLY The law prohibits employees of VA and the State Approving Agency SAA from owning any interest in an educational institution operated for profit. In addition the law prohibits these employees from receiving any wages salary dividends gifts or services from private profit schools. These provisions may be waived if VA determines that no detriment will result to the government or to veterans or eligible persons enrolled 38 U*S*C. 3683. Please list below those VA and SAA employees known by you who may have a potential conflict of interest under this provision* If there are none please enter the word none. NAME AND TITLE OF EMPLOYEES S DESCRIPTION OF ASSOCIATION WITH SCHOOL 2 ALL PROPRIETARY SCHOOLS 38 C. F*R* 21. 4202 C prohibits the approval of any veteran or eligible person in any proprietary school of which the veteran or trainee is an official authorized to sign certificates of enrollment or verifications/certifications of attendance an owner or an officer. Please list below the names and VA file numbers claim or Social Security Numbers of any certifying officials owners or officers of your school who receive VA educational assistance based on an enrollment in your school* If there are none please enter the word none. VA FILE NUMBER DATES OF ENROLLMENT WITH YOUR SCHOOL FROM TO I DO HEREBY CERTIFY that the entries above are true and correct to the best of my knowledge. See certifications 1 and 2 below. These certifications not only apply to chapters 31 and 36 of Title 38 U*S*C. but also apply to the following programs administered by the Department of Veterans Affairs VA MGIB Montgomery GI Bill-Active Duty Educational Assistance Program Chapter 30 of Title 38 U*S*Code VEAP Veterans Educational Assistance Program Chapter 32 of Title 38 U*S*Code DEA Dependents Educational Assistance Chapter 35 of Title 38 U*S*Code MGIB-SR EAPP Educational Assistance Pilot Program Section 903 of Public Law 96-342 1 PROPRIETARY PROFIT SCHOOLS ONLY The law prohibits employees of VA and the State Approving Agency SAA from owning any interest in an educational institution operated for profit. .

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