International Student Departure

Are you submitting any other online forms to our office?*

Yes No

List Additional OISPS Application You Are Submitting*

This form must be completed by students who plan to depart the United States or no longer wish to remain in F1 or J1 status.

Have you*

Attached Flight Itinerary Dropped Your Classes Paid Off The Tuition Fee

It is important that you meet all 3 requirements

Visa Type*

SEVIS ID*

LU ID #*

Name*

First Name

Middle Name (optional)

Last Name

Birth Date (MM/DD/YYYY)

Phone*

Email*

Forwarding Address*

Address Line 1

Address Line 2

City

State/Province

ZIP / Postal

Country

Reason for Leaving LU*

Please explain reason for leaving*

To:*

Reason:*

List the degree and completion date:*

List Reason for Leaving*

Dependent(s) Information

Federal regulations require dependents in F-2 /J-2 status to terminate their status and depart from the United States upon the termination of the principal F-1 /J-1 alien.

Date of Departure*

Flight Itinerary*

No File Chosen

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Disclaimer and Signature*

I certify that my answers are true and complete to the best of my knowledge.

Participant signature is required. Indicate your preferred format.*

Type name Sign using mouse

Participant Signature*

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Use your mouse or finger to draw your signature above

Typed name serves as participant signature*