Student Departure Form

Please complete this form to indicate your final departure from the U.S., especially if that departure date is earlier than the program end date on your I-20/DS-2019/EAD. Please mail, e-mail or drop off the form to International Programs. Do not fill out this form if you are: a) Transferring your I-20/DS-2019 to another educational institution. Please complete and submit the appropriate transfer-out form. b) Changing non-immigrant status within the U.S. Please submit a copy of the Change of Status I-797 Approval notice to IP. c) Leaving the U.S. temporarily, but have plans to resume your studies/research/OPT upon your return. If you will be outside of the U.S. for more than 30 days (except during approved vacation periods), please schedule an appointment to review your situation with OGE to discuss your options.

Email Address

Last Name

First Name

Banner ID

Academic Department

Immigration Status

F-1 Student

J-1 Student

J-1 Scholar

Other…

Completion Date

Departure Date from U.S.

Address

City/Town

State/Province

ZIP/Postal Code

Country

Please provide the address where you will be receiving your mail after you leave UNCP.

Alternative Email Address

Signature

I authorize OGE to complete/close/end my SEVIS record. I understand that once my SEVIS record is completed/closed/ended I will be able to remain in the U.S. for the grace period authorized for my status (F-1=60 days, J-1=30 days). I understand that after my SEVIS record is completed/closed/ended it will not be able to be transferred or reactivated. If my plans change I will notify OGE immediately.

By signing this form, I certify that I am signing this form on my own behalf and I have agreed to submit this application by electronic means. I also certify that my answers are correct and complete to the best of my knowledge.

Date

A copy of your responses will be emailed to the address you provided.

Student Departure Form

The University of North Carolina at Pembroke