FORT  HAYS  STATE  UNIVERSITY
STUDENT  INFORMATION  RELEASE  AUTHORIZATION
Dear Student:
Please fill in the Student Section information below, sign and date the form, and take to your current Foreign Student Advisor to have it
completed.  You are required to return the form to the Fort Hays State University Office of International Student Services.  If you have
any questions, please contact the office at the address listed at the bottom of this form. Thank You.
STUDENT SECTION
Surname/Family Name:
Social Security #:
Birth Date (mm/dd/yyyy):
Foreign Address:
City/State/Province:
Current U.S. Address:
City:
Given/First Name:
Country of Citizenship:
Birth City:
Middle Name:
Birth Country:
Postal Code:
State:
Country:
Zip:
Interim Address:**
City/State/Province:
Telephone:
Postal Code:
Current E-mail:
Country:
**Address where you will be after leaving your current school and before arriving at Fort Hays State University (if different).
I authorize the release of my information.
Student Signature: ______________________________________________
Date: _________________
FOREIGN STUDENT ADVISOR SECTION
Student’s visa type:
Visa expiration date:
Is this student currently in status?
Y
N
When was the student last considered to be a full-time student at your institution?
Semester:
Is the student in SEVIS?    ___ Yes
___ No
Year:
Date semester ended:
SEVIS ID number:
If not, anticipated date of entry into SEVIS:
If yes, is the student’s record currently in SEVIS as transfer out to Fort Hays State University?
___ Yes    When is the release date?        ___ No    The reason for No is:
Please indicate below any Curricular, Optional Practical or Academic Training granted to this student:
Complete for J-1’s only:  Program number:
Sponsor:
Length of time in U.S.:
Category in #4 of IAP-66/DS-2019:
Signature of DSO/RO/ARO:
Printed name and title:
Institution Name and Address:
Phone number:
Date:
E-mail:
PLEASE RETURN BY MAIL OR FAX TO:
Fort Hays State University
International Student Advisor
Sheridan Hall 208
600 Park Street
truncated file
Hays, KS 67601
Fax: (785) 628-4113
Phone:  (785) 628-4276
E-mail:  ***************

版权声明：本站内容均来自互联网，仅供演示用，请勿用于商业和其他非法用途。如果侵犯了您的权益请与我们联系QQ:729038198，我们将在24小时内删除。