July 2012
Student Information
Name: Date of Birth:
Last First
Phone: Cascadia Student ID #:
Email:
Local Mailing address:
Signature: Date:
Study Program: ____________________________________________________________________________
Did you complete your degree/program? (circle one) YES / NO
If No, explain: ______________________________________________________________________________
(e.g. withdrawal, family emergency, medical condition, etc.)
SEVIS ID: N____________________________
I am returning home to my country, AND… (choose only one):
I have no plans to return to the U.S. in the future.
It is possible that I will return to the U.S. but not to Cascadia. If you will transfer to another
college/university soon, remember to complete International Programs’ transfer out request form.
It is possible that I will return to Cascadia for _________ (quarter) ______ (year)
My last quarter of study at Cascadia will be: Fall / Winter/Spring/Summer Year: ________
Estimated Date of Departure from U.S.: _____ / _____ / _____ (month/day/year)
Student’s Signature Date
NOTE: If you are returning home, your I-20 from Cascadia becomes invalid as of the last day of your attendance. You
will not be able to use it to re-enter the U.S. (this includes trips to Canada).
To be completed by the International Programs Office
Advisor’s Initials Advisor’s Printed Name Date
□ Scan and E-file □ Email the student □ Update Database □ Update SEVIS
Cascadia College is an equal opportunity institution and does not discriminate on the basis of race, color, religion, gender and/or sex, disability, national origin,
citizenship status, age, sexual orientation, veteran’s status, or genetic information. All Cascadia materials are available in alternative formats and can be requested by
contacting the Human Resources office.
