OPT STEM Extension Request

Please complete the form and gather all the documents on the checklist to submit to International Student Office. Also, please pay OPT STEM application fee ($100) to Financial Department.

Name Name * First Last
SEVIS Number *
Address Address *
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Phone Phone * - ### - ### ####
Email *
Degree Information
My program of study: *
OPT STEM start date. OPT STEM start date. * / MM / DD YYYY
OPT STEM end date. Add 2 years minus 1 day to OPT STEM start day. OPT STEM end date. Add 2 years minus 1 day to OPT STEM start day. * / MM / DD YYYY
Most recent employer information.
Name of Company *
Company Address Company Address *
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Client's Name (If applicable)
Client's Address Client's Address
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Job Title *
Job Description *
EIN number. This is NOT E-Verify #. Contact your HR if you do not know this number. *
Employment Start date Employment Start date * / MM / DD YYYY
Employment End Date Employment End Date * / MM / DD YYYY
Supervisor's Last Name *
Supervisor's First Name *
Supervisor's Phone Number Supervisor's Phone Number * - ### - ### ####
Email *
Student Acknowledgement
I agree to notify the ISO through the OPT Student Employment Verification Form within 10 days if there are any changes in: my legal name, address, employer name, employer address, or loss of employment.
• I agree to report every 6 months while on STEM OPT to confirm my US address, employer name, and employer address, even if there have been no changes.
• I understand that I must complete two self-evaluations during the course of my STEM OPT period. The self evaluations are on page 5 of the Form I-983. I must submit it at 12 months from my STEM EAD start date and a second one at 24 months of my STEM OPT.
• I agree to submit a new Form I-983 if I begin a new practical training opportunity with a new employer or any time there is a change in the terms and conditions of the original I-983.

Draw or Type

I understand this is a legal representation of my signature. Clear

Full Name

I understand this is a legal representation of my signature.

OPT STEM Extension Request

OPT STEM Extension Request

Degree Information

Most recent employer information.

Student Acknowledgement