1706 Illinois Street
Golden, CO 80401
273-303-3210
www.isss.mines.edu
J-1 Exchange Visitor Extended Absence/Out of Country Request Form
Out of country absences of more than 30 days are subject to review by the International Office. This form must be completed and signed by
the J-1 and the J-1's host faculty member. After both of those signatures have been provided, bring this form and your DS-2019 to the
International Office. We will review it for eligibility. Take this form with you when you travel for your extended absence.
Family Name First (Given) Name:
SEVIS Number Host CSM Department
Out of country start date
Return Date to the
US
J-1's residential address
while abroad
J-1's
Email
Please provide a description detailing the purpose of this extended absence. Include how your activities abroad will be
related to your Colorado School of Mines program activity:
To be completed by the J-1 Exchange Visitor:
I am aware that I am required to maintain medical insurance which meets the J-1 program requirements during my time abroad.
At the the end of this absence period, I will return to CSM to continue my J-1 program.
Signature: Date
To be completed by the faculty host:
I am aware of and approve of this J-1's absence from the US. I will continue to monitor his/her progress during the time outside
of the US. I expect the J-1 Exchange Visitor to resume his/her J-1 program activities at CSM upon return to the US.
Host Faculty Name
Host Faculty Signature Date
To be completed by an advisor in the International Office at Colorado School of Mines:
This extended absence request has been reviewed, approved, and appropriately recorded in the J-1's record.
Signature Date
