Transfer Enrollment Form
65-30 Kissena Blvd., Flushing, N.Y., 11367 telephone: 718-997-5718 fax: 718-997-5723 email: inga.mezale@qc.cuny.edu
 
To be completed by the student: Before completing this form, you must make sure that you will be accepted to the ELI Program.
 
 
Name: ___________________________________ Date of birth: ___________________________________
student (family name, given name) date of birth (month/day/year)
 
Country of birth: ____________________________Country of citizenship: _____________________________
country country/ies
male female
U.S. address: ____________________________________________________________________________
street
 
_______________________________________________________________________________________________
city/state   postal code
 
Telephone: _________________________ Email: _______________________________________________
telephone number/s  
I intend to transfer to ELI at Queens College for (please check one): Fall Spring Summer I Summer II
 
I give permission for the information requested below to be made to the ELI.
 
 
Student signature: _______________________________________ Date:______________________________
  month/day/year  
 
To be completed by DSO at previous school :
 
 
Sevis ID number:______________________________ Sevis release date:* ______________________________
 
*SEVIS: Find us in SEVIS under:
The City University of New York – Queens College – ELI
(NYC 214F00812.023)
 
Is/Was the student maintaining F-1 student status as defined by INS regulations? Yes No
Do you recommend a
Transfer Reinstatement (If you select "reinstatement," indicate why in the comment section of this form.)
 
COMMENTS: _____________________________________________________________________________________
 
_______________________________________________________________________________________________
 
Name of previous school: ____________________________________________________________________________
 
 
Address of previous school: ___________________________________________________________________________
 
Telephone: ________________________________ Email: _________________________________________________
 
Dates attended: ______________ to ________________
 
 
DSO signature: __________________________________________________ Date:________________________
month/day/year
 
DSO printed name: ______________________________________________________________________________
 
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