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 email@example.com.
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
3. Has the student been delayed in completing the program requirements due to any periods?
of academic warning, limited enrollment, and/or suspension?
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?
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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