Mentor Language InstituteHollywood
7080 Hollywood Blvd., Suite 314. Los Angeles, CA 90028
Tel: (323) 870– 7102 Fax: (323) 488-9748 Email: hollywood@mliesl.edu

INS School File Number: LOS214F19660001

NOTICE OF INTENT TO TRANSFER
Dear Applicant:All students who are currently on an F-1 visa and wish to transfer to Mentor Language Institute - Hollywood(MLI) must have this status verification form completed by the institution you were last authorized to attend.
Name: _______________________________, __________________________________ __________________________
Last

First

SEVIS #: ________________________________

MiddleBirth Date: _______/________/________
Month/

Date/

Year

I intend to attend MLI on (starting date): _______/________/________
Month /

Date/

Year

My current USA Address: ______________________________________________________________________________
NumberStreetApartment #___________________________________________________________________________________________________CityStateZip CodePhone : (_______)__________________________________ Email: ___________________________________________
By signing this form, I am acknowledging my intention to attend MLI. I also give permission for my former school to release any needed information from my files.
___________________________________________/________/________

Applicant Signature

Month/Date/

YearDear International Student Advisor:
This is to verify that the above named student has applied for admission to MLI. Your cooperation is highly appreciated. Please provide
the following information and release the student to Mentor Language Institute - Hollywood (LOS214F19660001)

Name of Institution: __________________________________________________________________________________Institution’s Address: _________________________________________________________________________________
NumberStreetSuite #___________________________________________________________________________________________________
City

State

Zip Code

Phone : (_______)__________________________________ Fax: _____________________________________________
Designated School Official’s Name: _____________________________________________________________________
DSO’s Title: _________________________________ DSO’s E-mail: ____________________________________________
Student’s Status:

In Status

Not in Status

If “Not,” please provide an explanation: _____________________________________________________________________________________________________________________________
Dates of current session or last session attended — from: ______/_______/_______ to ______/_______/_______
Month /

Date/

YearMonth/

Date/

Year

Anticipated last day of attendance: ______/_______/_______ SEVIS release date: ______/_______/_______
Month /

Date/

YearMonth /

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Comments: _______________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Designated School Official’s Signature_______/_______/_______Month /

Date/

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_____________________
Official Seal / Stamp