Tennessee State University Immigration Form
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1Tennessee State University
Immigration Form
Dear International Student: If you are attending (or have attended) a US college or university, you must
complete this form. This form must be completed and returned before an I-20 can be issued.
Section I (to be completed by applicant)
Name:________________________________________email:__________________________________
Country of birth:__________________________ Country of citizenship:__________________________
Social Security #__________________________ Telephone #_____________________________
Present US address
Home Country Address
______________________________________
_______________________________________
______________________________________
_______________________________________
______________________________________
_______________________________________
When are you transferring? Check one: Fall_____ Spring_____ Summer_____ Year:__________
I request and authorize the School Official to provide Tennessee State University the confidential
information requested.
Signature:_________________________
Date:____________________
Section II (to be completed by DSO)
I-94 Admission Number:____________________
SEVIS ID:____________________
Dates of enrollment at your school: from____________________ to_____________________
(mm/dd/yy)
(mm/dd/yy)
To the best of your knowledge, is this student currently IN STATUS with DHS?
____yes
____no
(If no please explain)_______________________________________________________________________
Has the student completed any authorized period of Practical Training?
____yes
____no
If yes check what type:
____Curricular
____Optional
____Full-time
____Part-time
Dates of training: Begin____________________
End____________________
(
(mm/dd/yy)
mm/dd/yy)
What is the transfer out date in SEVIS? ____________________
(mm/dd/yy)
Signature of School Official: _________________________ Name of Official______________________
(please print)
Title:______________________________ email:_________________________
Name and Address of Institution:
____________________________________________________
____________________________________________________
Please return this form to:
Tennessee State University
Mark Gunter
International & Multicultural Affairs
Director
3500 John A. Merritt Blvd.
Telephone# (615) 963-5640
Nashville, TN 37209-1561
Fax: (615) 963-7771
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