Fillable Program Extension Request Form - Louisiana State University printable pdf download

PROGRAM EXTENSION REQUEST FORM

This completed form, supporting financial documentation forms, and a completed Green Sheet Request

should be submitted by the STUDENT to: International Services, 101 Hatcher Hall, Baton Rouge, LA 70803

· isosevis@lsu.edu · fax: +1-225-578-1413

This form is used to request a new I-20 (F-1 students) or a new LSU DS-2019 (J-1 students). A new I-20/DS-2019 is necessary if

the student is extending his/her program to a date later than the program end date listed on their current I-20/DS-2019. Note:

International Services can only change programs for DS-2019s that are issued by LSU and not other sponsoring organizations (J-1s).

**THIS FORM SHOULD NOT BE FILLED OUT BY THE STUDENT**

This form MUST be filled out by the Department of the program that necessitates the extension.

Any missing information will result in a delay of processing. Please type or print clearly.

The international student who provided this form to you has an I-20 or DS-2019 that is expiring soon. This form is a recommendation

from the student’s academic department that compelling academic reasons exist that necessitates the extension of this student’s

immigration document. Any questions about how to complete this form should be directed to isosevis@lsu.edu.

Name of Department: _______________________________________________________________________________

Name of Department Contact: ________________________________ E-mail:_________________________________

Department Phone: _________________________________________ Fax: __________________________________

STUDENT INFORMATION

Name:____________________________________________________________

LSU ID Number: _____________________

FAMILY

FIRST

MIDDLE

PROGRAM INFORMATION

1. Circumstances which necessitate extension (please check all that apply):

Unexpected research problems

Change of major or degree level from _________________________________ to _____________________________________

Change of research topics

Other academic reason (please give brief explanation): ___________________________________________________________

2. New Projected Completion date: ______________ _____

Degree-Only date: ______________________

(use commencement date)

MM/DD/YYYY

(use degree-only deadline) MM/DD/YYYY

Please note: Program extensions cannot be granted for the purpose of obtaining employment, Curriculum Practical Training (CPT),

Optional Practical Training (OPT), or J-1 Academic Training alone. There must be “compelling academic reasons” (8 C. F. R. 214.2

(f) (7) (iii)) and requirements for an extension of program.

FUNDING INFORMATION

- List all LSU sources of support for student for the duration of the program extension.

SOURCE

AMOUNT

DURATION (please select)

BEG. & END DATE

Full-Time Assistantship (20 hrs.)

$___________

9 or 12 mos.

__________________

Part-Time Assistantship(s) (10 hrs.) $___________

9 or 12 mos.

__________________

Graduate School Tuition Award

$___________

9 or 12 mos.

__________________

Graduate Supplement Award

$___________

9 or 12 mos.

__________________

Graduate Enhancement Award

$___________

9 or 12 mos.

__________________

Graduate Enrichment Award

$___________

9 or 12 mos.

__________________

Other Award:______________

$___________

9 or 12 mos.

__________________

Attach recent bank statement or affidavit of support

Personal/Family Funds

$___________

By signing this form, I certify that to the best of my knowledge, the information on this form has been reviewed

and provided by the department.

Graduate Advisor/Major Professor/Departmental Advisor:

Name:________________________________Signature:____________________________Date:____________________

Department Head:

Name:________________________________Signature:____________________________Date:____________________

10/22/2013 MP

Program Extension Request Form - Louisiana State University

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