jn: My Documents/Word Documents/Petition Forms/F-1 Student Exit Form 07/22/2014
All F-1 status students must complete this Exit Form during their last quarter at De Anza College. The
information requested on this form is needed to accurately update your record in the Student and Exchange
Visitor Information System (SEVIS), per Federal regulations regarding F-1 student. We ask that you assist the
International Student Programs by completing this form and returning it to our office by the end of quarter.
To Be Completed By Student
Last/Family Name First/Given Name Middle
*Student ID: Gender: Male Female Date of Birth: / /
*Required information mm dd yyyy
*SEVIS ID: N ( )
*Required information E-mail Address Phone Number
I-20 Expiration Date: (mm/dd/yyyy) EAD Expiration Date: (mm/dd/yyyy)
Please see item #5 of your De Anza College I-20 form Answer only if you are on PCOPT
Last Term of Study: Fall Winter Spring Summer Year:
My plans after completion of study at De Anza College (check all that apply):
Student must attach evidence of program completion form signed by academic counselor:
AA/AS Degree
Student may require to contact / meet with the Int’l Student Advisor on the following selections:
School Transfer attach Transfer Form and/or Admission Letter
(Student MUST complete this form prior to release in SEVIS)
Name of School:
Starting Date/Term:
Type of program (e.g. BS in Business):
Transfer to Foothill College (Transfer form not required.)
Return to home country (within 60 days after completion of study and/or OPT)
Return to home country (within 15 days without completion of study and/or OPT)
Return to home country and return with new I-20 issued by new school
Apply for Post-Completion Optional Practical Training (PC OPT)
Change my status from an F-1 student to:
Other (Please Explain):
I state that the information I am providing on this form is true. I further understand that it is a violation of U.S. law to give false information to the college.
Student Signature: Date:
For Office Use Only
Received by: Processed by:
Date: Date:
Please Return This Form to International Student Programs (ISP)
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