Signature: ____________________________________________
24255 Pacific Coast Highway, Malibu, California 90263-4246, USA ▪ Phone: +1 310-506-4246 ▪ E-mail: oiss@pepperdine.edu
To be completed by the STUDENT
After the DSO at the school you were last authorized to attend has completed the DSO portion below, submit this form
along with the other documents on your I-20 checklist.
Last Name ______________________________________
First Name ___________________________________
SEVIS ID ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___
E-Mail _____________________________________
Your Pepperdine education level:
Undergraduate
Graduate
Do you plan to travel outside of the U.S. before attending Pepperdine University? Yes No
Send Form I-20 to the following address:
_________________________________________________________________________________________
Street Apt City State Zip Code Country Telephone
_____/ _____/ _____
To be completed by the DSO
Please return the completed form to the student.
Dates of student’s attendance
Is the student in lawful F-1 status? Yes No Is there a pending reinstatement application? Yes No
_____/ _____/
_____
Month
Day
Year
Date of transfer release of student’s SEVIS record
Month Day
Year
__________________________________________ ______________________________________________
Name Title
_____________________________________________ __________________________________________________
Signature Date
_____________________________________________ __________________________________________________
E-mail Telephone
____________________________________________
School
__________ 214 F__________________________________
School Code
OFFICE OF INTERNATIONAL STUDENT SERVICES
IMMIGRATION STATUS VERIFICATION FORM
N
Date student’s record was:
completed terminated cancelled
_____/
_____/
_____
Reason ________________
Revised 8/15/2015
