International Student and Scholar Services 11139 Anderson St., SSC-102
Loma Linda, CA 92350-0001
(909) 558-4955
FAX: (909) 558-7949
Transfer Request Form
The student, named below, has been accepted into a program at Loma Linda University (LOS214F00109000)
that will begin on . We are requesting the transfer (release) of their SEVIS record. Please
mail or fax this completed form. If you have questions, call (909)558-4955.
Student’s Family Name, First/Given Name Date of Birth (mm/dd/yyyy)
To be completed by the Student:
Name (as it appears in your passport):
Family/Surname First/Given Middle (if applicable)
Current program/field of study:
Current program level or degree:
The last day of attendance at current school (mm/dd/yy):
By signing here, I authorize my current International Student Advisor to release the information on this form to
Loma Linda University.
Signature: Current ID # Date:
To be completed by the International Student Advisor:
G This student is eligible for transfer. The “Transfer out” release date is (mm/dd/yy):
G This student is not eligible to transfer for the following reason(s):
Comments, if any, regarding this transfer:
PDSO / DSO who processed this transfer request:
Signature Print Name & Title
Name of institution: Address:
Telephone number:
Date:
click to sign
signature
click to edit
![]()
click to sign
signature
click to edit
![]()
