Other Scholar Departure Form

SCHOLAR INFORMATION:
Scholar's Surname:
Scholar's First Name:
Scholar's Permanent E-mail:
Scholar's Date of birth: Scholar's Date of birth: / MM / DD YYYY
Scholar's Immigration Status:

Scholar's Immigration Status: O-1 F-1 OPT/STEM TN (not processed by IFSO) Non-UCSD J-1 Exchange Visitor Other (B-1, B-2, WB, WT, etc.)
UC SAN DIEGO DEPARTMENT INFORMATION:
Department Name:
Department Administrator Name:
Department Administrator Email Address:
DEPARTURE INFORMATION:
Date of Completion/Separation: Date of Completion/Separation: / MM / DD YYYY

If the Scholar was paid, the date of completion must match the separation date entered in PPS.
Date of Departure from the United States: Date of Departure from the United States: / MM / DD YYYY
Departure Date is Unknown:

Departure Date is Unknown: Unknown
Will you transfer to another UC San Diego department?

Will you transfer to another UC San Diego department? Yes No
Are you transferring to another U.S. Institution?

Are you transferring to another U.S. Institution? Yes No
Will you return to your home country?

Will you return to your home country? Yes No
Upload documentation relevant to your departure.

Attach Files

Up to five documents may be uploaded, simultaneously or one-at-a-time.
Additional Comments/Notes to IFSO: