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Departure Form

I certify that I am departing the U.S. and have no intention of returning to Cal State L.A. or another U.S. school in the next 5 months. I understand my departure date will be submitted to SEVIS and I will not be eligible to re-enter the U.S. on my current SEVIS I-20/DS-2019. It is my responsibility to notify International Office counselor of any changes to my immigration situation.

This form means that you are leaving the USA and NOT coming back.

Information
Family/Last *
First Name *
Middle Name
CIN
SEVIS Number *
Date Departing * Select Expected Date of Departing
Reason for departure *
Completion of program or Optional Practical Training (F-1)/Academic Training (J-1)
  • You must depart the U.S. within 60 days from your completion date or the end of the Optional Practical Training period(F-1). J-1 students must depart within 30 days from the completion of the program or expiration of the Academic Training.
  • Date of completion or end of employment
    authorization *:
    Select Expected Date of Completion
Early termination from Optional Practical Training (F-1)/Academic Training (J-1)
  • You must depart the U.S. within 15 days from your last day of employment.
  • Last date of employment *: Last Date of Employment
Early withdrawal from Cal State L.A. with approval from the International Office
  • You must depart the U.S. within 15 days of dropping your classes.
  • Date when you dropped your classes *: Last Date of Class
  • If you want to come back, you will have to make a new application and pay the application fee and the SEVIS I-901 fee.
Agreement *
I certify that provided information is correct to the best of my knowledge.

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Last Update: 10/24/2011