International Student Admissions & Programs
1601 Maple St. Carrollton, GA 30118
Phone: (678) 839-4780
Fax: (678) 839-5509
WITHDRAWL OR LEAVE OF ABSENCE
Federal regulations required the University of West Georgia to update the SEVIS record of any F-1 or J-1 student following a withdrawal
or leave of absence prior to a student’s expected graduation date. This form requires the signature of your academic advisor.
SECTION 1: STUDENT INFORMATION
Student’s Family
Name (Last Name)
Student’s Given
Name (First Name)
Date of Birth
UWG Student ID
917
Phone Number
SEVIS ID Number
N000
Email Address
Current Visa Status
F-1 Student J-1 Student Other Visa Type: Specify _______
SECTION 2: WITHDRAWAL OR LEAVE OF ABSENCE
Reason for
Withdrawal or Leave
of Absence
Date of Withdrawal
form UWG
Date of US Departure
Do you plan to return
to UWG?
YES NO UNSURE
If you are planning to return
Expected Return Date
NOTE: Returning students must contact the ISAP office 60 days prior to returning to the USA to attend the University of West Georgia.
Student’s Signature: ___________________________________________________________________ Date: ________________
SECTION 3: ACADEMIC ADVISOR OR DEAN RECOMMENDATION
I confirm that the above named student will be withdrawing or taking a leave of absence from the University of West Georgia and that
the information on this form is accurate to the best of my knowledge.
Signature
of Academic Advisor
Date
Printed Name
Title
Email completed forms to isap@westga.edu
