Visiting Scholar Notice of Departure

This form must be completed by all UW-Madison J-1 scholars who are terminating their J-1 programs, leaving the University of Wisconsin-Madison campus, and leaving the United States.

Scholar Information

Today's Date:(mm/dd/yy)
Last Name:
First Name:
Middle/Other Name:
Sponsoring Department
Date of Departure from UW-Madison: (mm/dd/yy)
Date of Departure from United States : (mm/dd/yy)

Home Country Address:

Note: In addition to submitting this form, you need to notify your department of your departure