Program Extension Application
for F-1 International Students
Office of International Student ServicesLiberty University, 1971 University Blvd., Lynchburg, VA 24515
Phone (434) 592-4118Fax (434) firstname.lastname@example.org www.liberty.edu/international
General Information: An F-1 student who is unable to complete degree requirements by the “Program
Completion Date” on the Form I-20 may be granted an extension by the DSO. To qualify, the DSO must certify
that the student has continually maintained status and that the delays are caused by compelling academic or
medical reasons, such as changes of major or research topics, unexpected research problems, or documented
illnesses. Delays caused by academic probation or suspension are not acceptable reasons for program
extensions. A DSO may not grant an extension if the student did not apply for an extension until after the
program end date noted on the Form I-20.
1. A signature approval on this form from your Academic Evaluator in the Registrar’s Office.
2. A signature approval on this form from the Embedded International Student Accounts Representative.
3. All students must be registered and financially checked in for the following semester.
4. Updated Degree Completion Plan Audit (DCPA) indicating classes completed and those that are still
outstanding (please print this from your ASIST account).
5. A bank statement proving funding for the additional semester(s). Must be sufficient to pay for tuition,
fees, and housing per USCIS regulations. Amount is determined by the financial information on your I-
20. *Note: if the bank statement is not in the student’s name, an accompanying sponsor letter must be
***Undergraduate students: Scholarships are granted for eight (8) semesters only***
To be completed by the student:
Name: Student ID #:
Program of Study: ____________________________________________________________________
Level: ___ Associates ___Bachelor’s ___Master’s
Please provide a brief explanation of why you did not complete your degree by the Program Completion Date:
Student Signature: Date: ____/____/_____
To be completed by Academic Evaluator in the Registrar’s Office:
Name and Title:
Student’s expected graduation date: ____/____/_____ (Date student will complete all degree requirements not the “walk” date)
The graduation date indicated above is valid for the program in which this student is enrolled.
Academic Evaluator Signature: Date: ____/____/_____
To be completed by the Embedded International Student Accounts Representative:
Name and title:
All students must receive approval from the Embedded International Student Accounts Representative
prior to being approved for a program extension. Signature: ____________________Date:____/____/_____
Return this completed form to your International Student Advisor for processing.