WALT DISNEY WORID@ Resort

Section I - Student lnformation

To be completed by the student. Pleasg print legibly on this form: Your full name ggg5llappear exactly as shown on ybur passport-

student Name: 5EfNffiUAMf n FIAN 6 ?I{97

Last Name/Family Name(s) First Name{s} Middle Name{s}

Pleose complete ONLY ONE Stqtement below:

o FIRST SEMESTER/FIRST YEAR COMPLETION: I hereby certify I am currently enrolled in or pursuing full-time studies in an accredited universiry
or tertiary level educational institution. I have compteted at least my FIRST (MAA( OUdveaat E SEMESTER of studies. *Officiot must
complete Section ll

. FINAL TERM: I hereby certify that I amrscrpleting my final term of an accredited university or tertiary level educational institution.
Graduation Date: _+Officiol must complete Section ll
DD/MM/YYYY
r GRADUATED: I hereby certify that I am a graduate of an accredited univerity or tertiary level educational institution.
Graduation Date: _* Attoch Degree/Diplomo
DD/MM/YYYY

lf you have previously participated in a Cultural Exchange Visitor Program sponsored by the WALT DISNEY WORLD@ Resort, please complete the
information below. This information can be found on your DS-2019 document. The SEVIS lD number is in the upper right corner of the DS-2019
document.

SEVIS lD tr Program Number From: DD/MM/YYYY To: DD/MM/WW SEVIS lD # Program Number From: DD/MMAYYY To: DD/MMAYYY

I hereby certify that all the information on this form is true, complete and accurate to the best of my knowledge I understand that providing false
;nfoi'matioi-i will lead to irnnrediaie termination of my lnterriaiionai t'icsiam.

studenr'ssignatrr"' b?{09lttb6, ae $e? &cr|E.

Section ll
To be completed by on
- University/Tertiary
authorized
Level Educational lnstitution lnformation
educotional institution/university representstive.

I hereby certify that the above student has been registered (enrolled) to attend out accredited university or tertiary level educational institution
since 0b /os l5 andhascompretedaileastthei TFTRiTIMARKrINEIFyEAR/flsEMEsrER.
DD/MM/YYYY

lF STUDENT lS lN FINAL YEAR: The student will complete coursework for a degree on:

Name of Universityfertiary Level Educational lnstitution:

I hereby verify that our Universityfl'ertiary Level Educational lnstltution is an accredited school in tt e.orntry 'Thrr,rrtcrq0l
of
t hereby certify that all the information on this form is true, complete and accurate to the best of my knowledge.

r'uu1+EL A. 7*uqnah!}cHiT e€+ il

Universiry/rertiaryLevelEducationallnstitUtionRepresentativeNamrionTitle:

University/Tertiary Level Educationil lnstitution Representative Signature:

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