International Affairs Office 

2f CCE Building 
Visca, Baybay City, Leyte, Philippines 
Email Address: i​ ntl@vsu.edu.ph 
Website: www.vsu.edu.ph 

OUTBOUND STUDENT FORM

Destination University / Institution:

Destination Country:
Name of Exchange / Internship Program:
Duration of Stay Abroad:
Start (dd/mm/yyyy): End (dd/mm/yyyy):

1. PERSONAL INFORMATION
First Name
Last Name
Middle Name
Sex [ ] Male [ ] Female
Birthdate (dd/mm/yyyy)
Birthplace
Civil Status [ ] Single [ ] Married [ ] Others:
Course & Year:
Student ID No:
Passport No.:
Date Issued (dd/mm/yyyy):
Expiration Date:

2. CONTACT INFORMATION
Home Address
E-mail Address
Phone Number

3. EMERGENCY CONTACT INFORMATION

Contact Person/ Coordinator of
your destination institution:
E-mail Address
Phone Number
 International Affairs Office 
2f CCE Building 
Visca, Baybay City, Leyte, Philippines 
Email Address: i​ ntl@vsu.edu.ph 
Website: www.vsu.edu.ph 

Contact Person in the Philippines:

Complete Address
E-mail Address
Phone Number

INSTRUCTIONS:
1. Accomplish 4 copies of this form and submit it to the International Affairs Office.
2. Attach the following documents:
a. Updated Transcript of Records from the Registrar
b. Photocopy of your Passport bio-page
c. Photocopy of your VSU Student ID
d. Letter of Intent (with research outline, if applicable)

I hereby declare that the information I have provided above are true and correct.

_______________________________________ __________________________
SIGNATURE OVER PRINTED NAME DATE

NOTED:

_______________________________________ __________________________
DEPARTMENT HEAD DATE

_______________________________________ __________________________
DEAN OF STUDENTS DATE

_______________________________________ __________________________
UNIVERSITY REGISTRAR DATE