Telephone: (510) 885-2880

International Programs Fax: (510) 885-2787

25800 Carlos Bee Boulevard, Room SF 102 E-mail: cie@csueastbay.edu
Hayward, California 94542-3012 alpfd@csueastbay.edu

I-20/TRAVEL REQUEST FORM

Check ALL that apply:

Endorsement for travel: we recommend Replacement I-20/DS2019 (Reason) : ___________

that you get an endorsement before
every trip outside the US

Renewing F-1 Visa Update major

Please print clearly. An incomplete request form cannot be processed. Bring this form to the International Programs
Office along with your passport and original I-20 or original DS-2019. It will take approximately 5 working days
to process this request.

Please place a checkmark which program you are currently enrolled:

Bachelors Intensive English Program

Masters Pre-MBA, Visiting, Certificates
Name _______________________________________________________________________________________
Last (Family/Surname) First Middle

Net ID ___________________________________ Degree/Major _____________________________

Current Visa Status __________________________ Visa Expiration Date ________/________/_______

U.S. Mailing Address: _________________________________________________ Apt______________________

City:________________________ State:____________________ Zip Code: _________________

Submit this form at least two weeks before your travel date

Traveling to ____________________________ Purpose of Travel ___________________________________

Approximate Departure Date: MM/DD/YY Approximate Return Date: MM/DD/YY

Dependents: If your F-2 dependents are traveling, please complete the following information:

1. Last Name __________________________ First Name ________________________________________

Date of Birth __________________________ Relationship to Student ______________________________

2. Last Name __________________________ First Name ________________________________________

Date of Birth __________________________ Relationship to Student ______________________________

I certify that the information I have supplied is true and correct.

_____________________ _____________ __________________ ______________@horizon.csueastbay.edu

Signature Date Phone Number E-mail address

Received By: _________ December 2016