Students who have attended a US institution within the last 5 months must have this form completed by your
Designated School Official (DSO). Once this form is complete please submit this form with your complete application
materials to San Diego Mesa College.
TRANSFER CLEARANCE VERIFICATION (TO BE COMPLETED BY THE DESIGNATED SCHOOL OFFICIAL- DSO)
Name of Student (AS IT APPEARS ON PASSPORT):
___________________________________________ __________________________________________ _______________________________________
LAST NAME FIRST NAME MIDDLE NAME
SEVIS ID#:
___ - ___ - ___ - ___ - ___ - ___ - ___ - ___ - ___ -___
Attendance dates at the school: FROM: ___________________________ TO ______________________________
(MONTH/YEAR) (MONTH/YEAR)
Last date (expected last date) of attendance: _____________________ SEVIS Release Date: _________________
(MONTH/DAY/YEAR) (MONTH/DAY/YEAR)
Is the student welcome to continue at your school? _________ Is the student in good academic standing? _______
Is or was the student academically disqualified? _______________________________________________________
Does the student have any financial obligation to your school? ___________________________________________
Has the student maintained full-time status throughout their attendance at your institution? If no, explain
________________________________________________________________________________________________
Type of program taken (English Language, Academic, Vocational/Technical, etc.):
_______________________________________________________________________________________________
Major course of study:
________________________________________________________________________________________________
List type and dates of all practical training authorized:
School Official’s Name
: ________________________________
SEVIS School Number: _______________________
(PLEASE PRINT)
School Official’s Title: _____________________________________ Email Address: ______________________________
(PLEASE PRINT)
Name of School: ________________________________________________________________________________
School Address: __________________ ______________________________________________________ _____________________________________
NUMBER STREET CITY
_______________ ____________________ _____________________
STATE POSTAL/ZIP CODE COUNTRY
School Official’s Signature: ___________________________________________
Date: _________________________________
International Student Program
Transfer Clearance Form
7250 Mesa College Drive, San Diego, CA 92111-4998
Phone (619)388-2717
San Diego Community College District-
San Diego Mesa College
(School Code: SND214F00408000)
