Program Extension Form

DEADLINE & REQUIREMENTS

Program Extensions MUST be completed and paid for within 21 days of your current program end date. Failure to do so will cause you to be out of status. Program Extensions require full payment of the program registration. A minimum of four weeks registration is required for Program Extensions, unless you are completing the program. **Students who have received permission to leave their ESL program early must depart within 15 days.

NOTE

Delay in completing your program caused by academic probation is NOT a valid reason for approval of an extension of program.

IF YOU WANT TO EXTEND YOUR PROGRAM, YOU MUST

1. Complete a Program Extension Form. 2. Provide an updated original bank statement if the one on file is 5 months or older. 3. Provide proof of health insurance coverage for the new program duration.

STUDENT INFORMATION

First name

Last name

Date of birth

Address

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

Phone Number

Current session end date

Session return date

New session start date

New session end date

Current i-20 end date

Sevis id #

Current Language Level

Completed language level?

Yes

Today's date

Name

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