INTERNATIONAL STUDENT SERVICES APPLICATION FOR F-1
STATUS PROGRAM EXTENSION
SECTION A: TO BE COMPLETED BY STUDENT
All non-immigrants in F-1 student status are required by federal regulations to complete their academic program
requirements OR obtain a program extension not later than the completion date listed in item 5 of the student’s
Form I-20. Failure to complete the program requirements or obtain a program extension by the end date is a
violation of non-immigrant status which must be reported to Immigration & Customs Enforcement.
FAMILY (LAST) NAME ______________________________________________
GIVEN (FIRST) NAME ______________________________________________
Do not write in
this box! ISS
use only!
TECH STUDENT ID# ____________________ DATE OF BIRTH _____________
Date Received:
E-MAIL ADDRESS _________________________________________________ _________
CURRENT MAJOR _________________________________________________ Date Complete
_________
LEVEL OF STUDY: BACHELOR OR MASTER
EXPECTED COMPLETION SEMESTER AND YEAR ______________________ Verify:
Funding
SEMESTER & YEAR YOU BEGAN CURRENT PROGRAM _________________ Advisor
GPA
WHY DO YOU NEED AN EXTENSION: (PLEASE DESCRIBE IN DETAIL) F-1Status
______________________________________________________________________________
SEVIS Action:
______________________________________________________________________________
Update Funds
Extension
Other
______________________________________________________________________________ ___________
___________
______________________________________________________________________________ ___________
CHECKLIST OF SUPPLEMENTAL DOCUMENTS FOR EXTENSION: ___________
Bring ALL of these items with you for your extension appointment!
Academic advisor’s verification form (Section B on next page of this application)
Updated proof of financial support (no more than 6 month old)
Past I-20 form previous programs/levels/schools/etc.
IMSSO Advisor:
Passport (should be valid at least six months into the future)
___________
CONTINUED ON NEXT PAGE!
APPLIC
ATION FOR F-1 STATUS PROGRAM EXTENSION
SECTION B – ACADEMIC ADVISOR’S VERIFICATION
STUDENT’S NAME __________________________________________________________
STUDENT’S TECH ID NUMBER______________________ DATE ___________________
To the student: DO NOT fill in any information below this line.
To the academic advisor; the student named above holds F-1 non-immigrant status and is required by the
Department of Homeland Security to obtain a program extension if he/she will not be able to complete the
academic program listed on the current Form I-20 by the end date at item 5 of that form. Please assist us in
evaluating the student’s request for extension by completing the following information. If you have any questions or
concerns, please contact Yasushi Onodera, IMSSO Director, at 964-0832 or yonodera@atu.edu.
1. Is the student named above currently in good academic standing? Yes No
2. Is the student making normal and satisfactory progress in his/her degree program? Yes
No
3. Has the student been delayed in completing the program requirements due to any periods?
of academic warning, limited enrollment, and/or suspension?
Yes No
4. Please indicate the reason(s) the student needs additional time to complete the degree program:
Change of major/program Unexpected research problems
Difficulty with English language Delays due to internship
Medical condition or illness (student must attach a doctor’s statement it this is selected)
Other compelling academic reasons (please attach letter with description/explanation)
5. Do you recommend that the student be given a program extension?
Yes No
6. Semester and year you expect the student to complete all degree requirements _________________
7. Please add any comments you feel appropriate in the space below or by attaching a letter:
ADVISOR’S NAME AND TITLE ________________________________________________________
ADVISOR’S SIGNATURE _____________________________________________________________
ADVISOR’S PHONE NUMBER _____________________________ DATE ______________________
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