Departmental I-20 Request Checklist
for On-Campus Residencies
Please submit this request form at least 4 months prior to the upcoming residency in order to have an I-20 issued for your student to
attend the mandatory residency in the F-1 student immigration status. Incomplete requests will be returned to your department. If the
completed form is received by ESS at least 4 months prior to the residency start date, the I-20s will generally be issued within 1-2
business days from the receipt of the request. Please scan and email the request to the International Admissions Coordinator in
ESS at least 4 months prior to the residency start date to help ensure your student will have the I-20 on time for his/her visa
application and travel for the residency.
Student’s Passport Name: ____________________________
(Last)
______________________ Banner ID: __________________
(First)
Request Submitted By: ____________________________________ Date Request Submitted to ESS:__________________
► I hereby certify that all information I am providing on this form is true and correct. I understand that the information I have provided will be used for
Federal Government reporting and I-20 issuance purposes. I am aware that the DSO creating the I-20 is certifying for the federal government under
penalty of perjury that all information on the I-20 is correct. I must notify ESS within 2 days if any of this information changes.
Signature (mandatory): ______________________________________________________________________________
►Has the student been admitted for a full course of study, & have ALL admission requirements been met? ___Yes
___No
►Please answer the following questions or attach the answers to this request:
____1. Reason for I-20 request: □ Required Residency □ Required Exam □ Other, Please explain: _________________________
____2. Degree the student will be pursuing: □ Master’s
□ DMin
□ DSL
□ EdD
□ Ph.D
□ Other: _____
____3. Specific title of student’s major : ____________________________________________________________________
____4. What are the dates the student is required to be on-campus for the residency/exam? From: __________ To: ___________
____5. Will the student be coming for a specific educational objective that supports full-time participation of at least 18 hours per
week during the residency/exam dates you listed above?
□ Yes
□ No
____6. How many credits will the student be enrolled in for the entire semester in which the residency occurs?
On-campus credits (MAT) _____ Online credits (MAD) _____
____7. Will all of the residency classes/instruction/activities be taken at the Virginia Beach campus? ___Yes
___No
*If not, list the address and phone number of any additional sites or locations where classes/instruction/activities will occur:
Address: ________________________________________________________ Phone Number: ____________________
(Please note that advanced approval, and a fee payment of $655, are now required by SEVIS for all off-campus sites where classes or
instruction is being provided to international student visa holders. It may take 3-9 months to obtain government approval.)
____8. Will any housing, meals or transportation costs be covered by the department and/or included in the program fees?:
□ Yes
□ No
If “Yes”, please list exactly what will be covered:
_________________________________________________________________________________________________
____9. Will the student be required to attend another Residency at Regent? □ Yes □ No
□ Not Entirely Sure
If “Yes”, what are the approximate dates of the next Residency? From: ____________ To: _____________
____10. Student’s telephone number (including country code): ______________________________________________
____11. Student’s personal email address: _____________________ Student’ Regent email address: ____________________
____12. Current MAILING address where the I-20 should be sent: Student’s PHYSICAL Home Country Address
________________________________________
(if different from the Mailing address):
________________________________________
________________________________________
________________________________________
_______________________________________
________________________________________
________________________________________
*Date Address is Valid Until: _________________
Revised on 3/27/12