Action Request Form Clear

Please submit this form at least two weeks in advance.

Student Name Paula Cristina de Melo SEVIS ID N00 30136199

Phone Number 508-723-2366 E-mail pmelo2908@gmail.com
Request Date 4/26/21 (MM/DD/YYYY) LDA (School Officials Only) 4/26/21 (MM/DD/YYYY)

 U.S. Vacation 05 03 2021

Start Date: _______/_______/_______ 07 03 2021
End Date: _______/_______/_______
MM DD YYYY MM DD YYYY

 Leave of Absence I will visit __________________________________________ (city / country)

 Transfer New School Name: __________________________ Phone: __________________

 Termination of I-20 Effective Date: ________/________/___________ E-mail: __________________

MM DD YYYY
(Cancellation / Withdrawal)

 Official Documents Verification Letter Transcript Certificate Other:

 I-20 Extension Lost Stolen Damaged Other:

 Appeal / Other Action

I have read and understood the Student Handbook, the procedures, and implications for returning to my course of study or failing to return following the
vacation. If you need an interpreter, please ask your director.
Student Signature:

School Officials ONLY (Refer the Student Handbook for the Refund Policy. If you still have any questions, please ask your director)

Refund Calculation (Completed by CFO Only)

1. (_________) weeks of program completed divided by (_________) weeks of program prepaid = (__________) %. (1 session = 8 weeks)
2. Multiply by prepaid tuition = $ (______________)
3. Minus a total amount of reduced tuition by any promotion (if applicable) = $ (______________)
4. Minus non-refundable fees (if applicable) = $ (______________)
5. Final total tuition to be refunded = $ (______________)

Is this ARF approved? ( Y / N )* by: Date:

Remarks:

* Please notify the student of your decision today.

There is a $20.00 record processing fee for any official letter, transcript, and I-20 after an initial official transcript and I-20. There is a $150.00 class change fee after the first
week of the session. Please allow at least 5 business days for processing requests, however additional time may be needed on a case-by-case basis.

Revised 11-24-2020