Student Departure Form

IMPORTANT REMINDER FOR STUDENTS

Reasons for departure include completion of program, early withdrawal from classes, or a break from studies due to an emergency. • Students who have received permission to leave their ESL program early must depart within 15 days.

▌ STUDENT INFORMATION

First Name

Last Name

Country of Birth

Birthday Date

Current Language Level

Completed Language Level

Phone Number

Session Return Date

Last Day Of Current Class

Program End Date

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Withdrawing From NATI ESL's Program

I have not completed the initial 6-week session and will withdraw from my classes. I understand that my SEVIS I-20 record will be terminated, and I will not receive a refund.

I will take a break due to a family emergency.

I have completed my program and will be leaving the U.S. within 60 days.

I will be outside the U.S. for more than five months. I understand that my SEVIS I-20 will be terminated.

I will be outside the U.S. for less than five months. I understand that my SEVIS I-20 will be terminated.

Please select one

SEVIS NOTICE

I understand my departure date will be submitted to SEVIS, and I will not be able to re-enter the U.S. on my current SEVIS I-20 if I leave early from NATI ESL's ESL program. In order to return to the U.S. and return to NATI ESL's ESL program, I will need to apply for readmission one month before my requested return date in order to get a new SEVIS I-20.

STUDENT'S SIGNATURE(Required)

Type your formal name

Phone

This field is for validation purposes and should be left unchanged.