PCC ID#:______________________ SEVIS ID#: N00_________________________
mm/dd/yyyy
Date Leaving U.S.:___________________
Last Date of Enrollment: ______________ Degree/Certificate Earned
mm/dd/yyyy
_______________
_______________________________________________________
___________________________
_
Departure Notification Form
NOTICE: Pursuant to U.S. immigration laws and regulations, the International Student Center (ISC) is required to ntify various
Federal agencies when an international student terminates his/her relationship with the College. Your cooperation in
ensuring College compliance with this requirement is appreciated. Please submit this form to D-204.
Student Name: _________________________________
_ __________________________________________ ___________
Family Name First Name MI
Date of Birth: _______________________
Major : _____________________
PCC email :________________________________
mm/dd/yyyy
degree type
Please check the reason for departure from PCC:
Early Withdrawal – I understand that I have a grace period of 15 days to depart the U.S upon submitting this form.
Reason for withdrawal:
Terminated – I understand that I must depart the U.S. immediately and have no grace period.
Graduated – I understand that I have a grace period of 60 days from my graduation date to depart the U.S.
Completion of OPT – A student must complete all practical training within a 14-month period following the completion
of study [Sec. 214.2(f)(10)]
Home Country
Address:
_______________________________________________________________________________________
____________________________________________________________________________________________________________
Email Address: __________________________________________ Cell Phone Number: _________________________________
Home Country Phone Number: ______________________________
I state that the information I am providing on this form is true. I further understand that it is a violation of United States law to
give false information to the college.
My signature below is in agreement of the time period I have to leave the U.S. It is my responsibility to drop all classes, and
determine whether or not I am eligible for a refund.
Student Signature mm/dd/yyyy
Important Notes:
You are responsible for dropping all of your PCC courses. Please check the refund deadlines to determine whether or not
you will receive a refund for the dropped classes.
ISC staff tocomplete:
Unit # _____ SEVIS SARS Request log
Ema
il A&R Email student
Initial: ______ Date: _______
Important Note: All paperwork requests require 10 business days to process. revised 4/25/2018
