Attachment III

Request for Additional Action Form for a Texas State University Memorandum of Understanding (MOU) or International Inter-Institutional Agreement (IA)

Please complete the information in the space provided and forward by email to the International Office at International@txstate.edu.

1	Texas State representative completing form: I am the university representative or academic program director (APD) for this MOU or IA: (√): □ yes □ no Name: Title: Department: Email: Phone number: Fax number: Mailing address:
2	Title of the MOU or IA:
3 (√)	□ Extension of a current MOU or IA
a (√)	□ My department, the university representative or academic program director (APD) for the MOU or IA and the corresponding department and university representative or APD at the international institution wish to extend the current MOU or IA for ______ years with a proposed new end date of __________.
b	Please provide date specific information demonstrating the MOU or IA is accomplishing its goals. 1) Please list the number, names, and activities of the faculty involved. 2) Please list the number, names and dates of the exchange of the students involved since the agreement was signed
c	Please attach email communication or other documentation that certifies this mutual desire and an updated draft version, if one exists.
4 (√)	□ Add an addendum to an existing MOU or IA
a (√)	□ My department, the university representative or APD and the corresponding department and university representative or APD at the international institution wish to add an addendum to the current MOU or IA. Activities related to this addendum would take place for ______ years with a proposed end date of __________.
b	Please attach email communication or other documentation that certifies this mutual desire and approval by the corresponding International Office at the international institution.
5 (√)	□ Edit an existing MOU or IA
a (√)	□ My department, the university representative or APD and the corresponding department and university representative or APD at the international institution wish to edit the current MOU or IA.
b	Please attach a copy of the current MOU or IA with the proposed edits and documentation and approval by the corresponding International Office at the international institution that they support the edits.
6 (√)	□ Terminate a current MOU or IA
a (√)	□ My department, the APD and the corresponding department and APD at the international institution wish to terminate the current MOU or IA.
b	Please attach email communication or other documentation that certifies this mutual desire, which includes approval of the proposed termination by the corresponding International Office at the international institution. If the termination action is not mutual, please describe the circumstances leading to this decision below.
7	Name and Signature of Texas State Department Head Name and Signature of Texas State Academic Dean

Note: The use of courier services such as Fedex, DHL or other similar services is strongly recommended when sending MOUs or IAs to international institutions that involve requests for additional action. The Texas State college, department or office initiating the MOU is responsible for costs related to the use of courier services for this purpose.