OFFICE OF INTERNATIONAL PROGRAMS
One UTSA Circle, 1.210 Main Building
San Antonio, Texas 78249-0621 USA
Tel: (210) 458-7230 Fax: (210) 458-7222

Authorization Release Form

This Form is to authorize the individual identified in the "RELEASE TO" section of this form to obtain document(s) and/or information from the International Student Services on your behalf. This Release Form will be valid for (30) days.

Date:
 Student ID:
Student’s Last Name:
First Name:
Address1
Address2
City/Town:
State/Province:
Country
 Zip Code:
Tel No::
 E-mail:

I, , hereby authorize the International Student Services to release and provide the specified document(s) and information listed below to the undersigned individual. I understand that the named individual should bring picture identification as a form of security in order to receive my documents and this individual would identify their birth date if he/she would call International Student Services to receive information about my visa record..

  Release the Following Document(s) and/or Information Relating To:
Form I-20 / DS-2019
OPT Authorization Card
OPT/OPT Receipt/Approval Notice
STEM Extension
Cap-Gap Extension
Other:
RELEASE TO: Name:
Relationship to you:
Address(if requested to
mail to a US address only)
_______________________________________________________________________________________________________________________________________________________________

For OIP office use only: Date of release:________________ Form of ID:________________________OIP Personnel initial: _________ (This release will expire thirty (30) days after date of request. )