Departure Form | Cal State LA

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.

Family/Last

First Name

Middle Name

CIN

SEVIS Number

Date 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.]

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.]

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. 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.]

Date of completion or end of employment authorization *

Last date of employment

Date when you dropped your classes

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