Program Extension Form

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INTERNATIONAL STUDENT - PROGRAM EXTENSION FORM
T
S
:
O BE COMPLETED BY THE
TUDENT
Student Name: (Last, First): ___________________________________________________________________
Tel. # ______________________________________
E-Mail ___________________________________
Expiration Date Stated on #5 of the I-20:
_______/_______/____________________________ (MM/DD/YYYY)
CAS: ______
EDU: ______
NHP: ______
SPS: ______
Bachelor’s: ______
Master’s: ________ Major: ________________________________________________
TO BE COMPLETED BY THE APPROPRIATE ACADEMIC ADVISOR
We have been informed that the above-mentioned student will require additional time to complete his/her program.
USCIS (Citizenship and Immigration Services) will permit our office to extend a student’s academic program for
compelling academic or medical reasons [8 CFR 214.2 (f)(7)(iii)]. Please note that delays caused by academic
probation or suspension, are not acceptable reasons for program extension.
1. Has this student been continuously enrolled for a full course of study?
__ Yes __ No
2. This student will complete requirements for his/her current program on/or about: _____/_____/_____
3. This student has not yet completed the current program of study due to (please check all reasons that apply):
Delays caused by a change in major;
Delays caused by unexpected research problems;
Delays caused by lost credits upon transfer to our school;
No unusual delay. The original length of time given to complete studies was not reasonable for an average
student in this program;
Other (please explain here; continue on reveres if additional space is needed):
______________________________________________________________________________________________________________________________
_____________________________________________________________________________________
4. _____ I therefore recommend that this student be allowed additional time to complete studies.
OR
5. _____ This student's delay in completing his/her academic program was not caused by any reason listed
above. Therefore, I do not recommend and extension of program time.
Name of Counselor: _____________________________
Title: __________________________________
Phone number: _________________________________
Email: _________________________________
Signature: _____________________________________
Date: ______/_______/____________
Hanan M. Adnan . International Students Advisor/DSO . Tel.. (202) 884-9141 . Fax (202) 884-9123 .
Email:
adnanh@trinitydc.edu

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