Fillable Sevis Form I-20 Application - Hcc (Page 2 of 3) in pdf

5. Dependent Information (Only the student’s spouse or children under the age of 21 are eligible for

dependent status)

_______________________________

_________________________

__________________________

Family Name

First Name

Middle Name

_____________________

__________________

____________________

Date of Birth (MM/DD/YY)

Country of Birth

Country of Citizenship

Relationship to applicant

•

If more than one dependent, please attach additional pages. Additional supporting documents such as

marriage certificate, birth certificates and copy of passports (or I-94 for COS) will be required for upload

in the passport checklist item.

*6. Financial guarantor’s information:

_______________________

________________________

____________________________________

Guarantor’s Name

Relationship to applicant

Guarantor’s contact information: phone/email

* 7. Permission to pick up or mail SEVIS Form I-20:

Choose one of the following options and provide necessary information:

I authorize my SEVIS I-20 to be:

Picked up

at the

office by:

Name

____________________

Phone (___) ___ ___ Email________________

Mailed to

Name

___________________

Address ___________________Apt._________

City

________________State/Province Postal Code:______________________

Country

____________________

I consent to the release of my education records to person(s)/agent listed above. I understand that my education record

includes, but is not limited to, my enrollment and immigration status and financial standing. I am waiving my rights of

nondisclosure of these records under federal law only to the person(s)/organization(s) specifically listed above.

8. Acknowledgement of Responsibilities and Liability Notice

By signing this application below, I confirm that I have received and read the guidelines outlining the responsibilities for F-

1 students to maintain legal F-1 status in the United States while studying at Houston Community College (HCC). I further

understand by signing below that failure to comply with these guidelines and regulations can and will result in loss of legal

status in the United States. Furthermore, I acknowledge that in consideration and as a condition of my acceptance to

HCC, I have an obligation to meet with an International Student Advisor/Designated School Official (ISA/DSO) at the

Office of International Student Services & Study Abroad (OISS&SA) for any and all immigration advising related to F-1

issues.

The ISA/DSO is not an “Advocate” or “Representative” for the student in any legal capacity. I understand that ISA/DSOs

and other HCC employees do not provide legal advice to students. Therefore, I hereby release all ISA/DSOs and

employees of HCC of any and all liabilities resulting from the advice given by an ISA/DSO or staff member of the OISS. All

matters relating to the immigration status of the student is the student’s responsibility, not the responsibility of HCC. If a

Rev. 03/2017

2 of 3

Sevis Form I-20 Application - Hcc Page 2

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