USA English Language Center Student ID:

SAN DIEGO UNIVERSITY FOR INTEGRATIVE STUDIES

LAST DAY/ CANCELLATION REQUEST FORM PG. 1

1. Name:____________________________________________ Today’s Date:________________

Class:_______________ Phone:_____________________ Email:______________________________

2. Last day of class at USA English Language Center: _____/_____/______

MONTH DAY YEAR

3. Reason for ending your Program (choose which option applies to you)
Leaving the United States

Transferring to another Language School in the United States

Name of the school you are transferring to:__________________________________

Transferring to another University or College in the United States

Name of the school you are transferring to:__________________________________

Transferring to SDUIS Degree or Certificate Program

\

F 1 Student Visa:

Attendance Policy - 80% attendance is required to maintain your I-20 record Active Status. Failure to maintain the attendance
requirement will result in termination and you will have to depart the United States.

60 Day Grace Period for U.S. Departure Upon Program Completion - F1 students must take action to maintain legal status
or depart the United States after completing your program of study. Once you complete your program of study, F students have
60 days after completion of your program to leave the United States.

Student Signature & refund information on reverse side

For Office Use Only Last Day Form Check List

- The dates on this form are accurate
For
- Office Use Only
Payments were
checked
- Attendance was checked _________________
- Form completely filled out, Including Student Signature USA ELC Advisor Initial

3.2017 Page 1 of 2
 USA English Language Center Student ID:

SAN DIEGO UNIVERSITY FOR INTEGRATIVE STUDIES

LAST DAY FORM- STUDENT REFUND SECTION PG. 2

Name:____________________________________________ Today’s Date:________________

4. How would you like to receive your check: Pick up in the office Mail (Provide Address Below)

• Please note it may take up to 45 days for your check to be ready, you may provide a mailing address below

Mailing Address: __________________________________________________________________

________________________________________________________________________________

Additional comments ___________________________________________________________________________

________________________________________________________________________________________
5. I have reviewed and understand the USA ELC cancellation and refund policies and procedures listed on
this form: Tuition refunds can take up to 45 days processing once this form is received by the administrative office and
your last day has been processed. Students will be contacted when the refund is ready. Refunds are in the form of check
in the name of the student. If check is not picked up after 45 days it will be mailed to the address on this form. Forms
without mailing address indicated will be mailed to last known address on file.

STUDENT SIGNATURE: _____________________________________ DATE: _________________

Section Below for Office Use Only

Refund Calculation:
AM / AFT / EVE / Wknd Last Payment Period Details: Last Amount Paid:

Dates Paid: FROM: _______________ TO: _______________ Number of Days:

Last Day: _______________ Days Attended: _______________ Days Refunded:

Section below to be filled out and attached with Student Check Request form to bring to FRC. (not for last day use)
Request reviewed by: _____________________________________ FRC Meeting Date: _______________
Important Details related to request being made. Check student’s file notes: ______________________________

Comments and Contigencies:_____________________________________________________________________

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