Revised 02/03/2017 Page 1 of 1
Part B: To be completed by a Designated School Official (DSO) at last school attended:
Name of Institution: __________________________________________________________________________
Address of Institution: ________________________________________________________________________
___________________________________________ Phone Number:_______________________________
Dates of Attendance: _________________________________________________________________________
Is this student’s current SEVIS record in good, active standing? YES NO
If “NO” please explain:________________________________________________________________________
Does the student have any outstanding financial obligation at your school? YES NO
If “YES”, please explain: ________________________________________________________________________
SEVIS Release Date: __________________________________________________________________________
*IF SEVIS record is “completed” or “terminated” please DO NOT transfer unless authorized by EVC DSO.
Name & Title: ______________________________________________________________________________
Official Signature: _________________________________________________ Date:______________________
Return by email or fax: or fax: (408) 274-7567.
Part A: To be completed by Student:
Name: _____________________________________________________________________________________
Last First Middle
SEVIS Number: ______________________________________________________________________________
I authorize a school official at my current school to provide Evergreen Valley College International Student Program (ISP) Office with the
information requested below.
Student Signature: _____________________________________________ Date: ________________________
Evergreen Valley
Evergreen Valley College (EVC) SEVIS School Code: SFR214F00283000
According to 8 CFR 214.2 (f)(8)(i), in order to transfer to a new school, you must have been continuously
enrolled as a full-
time student at your present school or have been reinstated to student status by the Bureau of
Citizenship and Immigration Services. Before International Student Program (ISP) Office can issue you
a new I-20, your prior school must release your SEVIS record to Evergreen Valley College. In order
to facilitate this process, please have the foreign student advisor at your present school complete this form. Once
completed, the advisor should mail, fax or e-mail the form directly to the International Student Program (ISP)
Office using contact information provided at the bottom of this form
International Student Program (ISP)
Evergreen Valley College, 3095 Yerba Buena Road, San Jose,
CA 95135 Phone: 001.408. 223.6740 Fax: 001.408. 274.7567
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