Program Extension Other

							                 Language Center International
                                       Request for I-20


 Mr.          Mrs.         Ms.


E-mail address _______________________________


Family Name ________________________________________________________
First Name ______________________________________________________
Middle Name _____________________________________________________
Date of Birth (month/day/year) _____________________________________
Gender          Male                  Female
Country of Birth ____________________________________
Country of Citizenship _________________________________


Foreign Address (Please write clearly)
         Street ____________________________________________________
         City __________________________________________________
         Province _____________________________________________________
         Postal Code/Zip Code ___________________________________
         Country ___________________________________________


U.S. Address (If living in the U.S.)
         Street ____________________________________________
         City ____________________________________    State ______________
         Zip Code ___________________________________________
         Home Telephone _________________________________________
Program Start Date: ____________________________________________
Reason for I-20 (Please check all that apply)
        Initial Attendance (no previous I-20)
       __ School Transfer
               Name of School _______________________________________
        Reinstatement
        Program Extension
        Other ____________________________________________________
        Dependents (Please write dependent(s) name(s) below)

                  Last Name           First Name     Date of Birth   Country of Birth   Relationship




When my I-20 is ready,
        I will pick it up    Mail it to U.S. Address     Mail it to Foreign Address


Student’s Signature ___________________________________Date_________


LCI STAFF USE ONLY
Application Reviewed by ___________________________________Date______________
I-20 Picked up/Mailed on ______________________________________