Last Name First Name Middle
Street Address (include apt. #) City State Zip Code
Home Phone Number Alternate Phone Number
Student I-20 Number Email Address
The student is currently a student at in visa status.
College or University Visa Status
The student is in good standing. YES NO
The student has permission to take courses at Midlands Technical College as a transient student. YES NO
The student has permission to take courses for which term? (check one) FALL SPRING SUMMER
The student will remain on our I-20 and MTC bears no responsibility for maintenance of their status in SEVIS. AGREED NO
International Advisors Name (please print)
International Advisor’s Signature Date
Telephone Number Email Address
This form will also serve as verification of lawful immigration status as required by SC state law. After you have completely filled in the
above information you can scan the form and email it to or send by mail to the address listed below.
Return this form to:
Admissions Office
Midlands Technical College
PO Box 2408
Columbia, SC 29202
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