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Last Name

First Name

SEVIS Number
(Number listed above the bar code on your I-20, ex N000012345)

Email Address
(Please use an email address that you check frequently)

Street Address

City

State

Zip

Phone

Degree Received:

OPT Start Date:

OPT End Date:

For students currently employed please list your current employer's name and address. If more than one, please list all current.

I am Currently Employed (or will be employed in the future)

Employer (Primary or future employer)
Name of employer:

Street Address:

City: State:

Zip:

Future Employer Start Date:

Additional Employers (if any)

Name of employer:

Street Address:

City: State:

Zip:

Any additional Employers, including volunteer work, enter here:

I am self employed

Type of business:

Business Address (can be personal address):

City: State:

Zip:

Currently have EAD card, but I am not currently employed. I am actively seeking employment

OPT application pending

I have changed my status from F-1 to

I have permanently left the country and have no intention of completing OPT