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Staff meeting agenda

International Students & Programs Office
International Center, 9500 Gilman Drive, Mail Code #0018 F-1 STUDENT: STEM EXTENSION OPTIONAL PRACTICAL TRAINING
(OPT) REQUEST FORM

DIRECTIONS:
Student must complete Section #1, #2, and #3A. Employer must complete Section #3B.
A complete application will include:
STEM Extension OPT Request Form
Copy of I-94 card (front and back)
I-765 application form (available at www.uscis.gov)
Copy of current I-20 (page 1 and 3)
I-765 application fee
Copy of official transcript, unofficial transcript or a
Copy of valid EAD card (Form I-766)
copy of diploma showing the level and program of study Copy of passport biographical page
2 US-style passport photos
Copy of F-1 visa page or change of status to F-1
approval notice (Form I-797)
Please submit all required documents of the entire application to the UCSD International Center and allow 10
business days for processing. NOTE: USCIS must receive your I-765 application packet before the expiration date on
your EAD card. Please plan accordingly.
SECTION 1: PERSONAL INFORMATION

Name:
______________________________________ UCSD PID#: _____________________________________
E-mail Address: ____________________________________ Telephone: _______________________________

Completion Date of UCSD Program:
__________________ UCSD Major: _______________________________

Employment Authorization Dates (see EAD card): from
_____________________ to _____________________

Do you have a pending application at USCIS (Attach copy of your I-797 Receipt Notice):

For an H1B visa? □ Yes □ No
If yes, indicate application date: ______________________
For an Immigrant visa? □ Yes □ No
If yes, indicate application date: ______________________

SECTION 2: EMPLOYER INFORMATION

Job Title or Position: ___________________________________________________________________________
Employer’s Name: _____________________________________________________________________________
Employer’s Address: ___________________________________________________________________________
Supervisor’s Name: _______________________ Email: ______________________ Telephone: ______________
Employer’s Name as listed in E-Verify: ___________________________________________________________
Employer’s E-Verify Company Identification Number or a valid E-Verify Client Company Identification
Number:
_____________________________________________________________________________________
SECTION 3: STUDENT AND EMPLOYER CERTIFICATION
A) F-1 students with approved STEM Extension Optional Practical Training (OPT) are required to report to the
UCSD International Center any changes in their name and/or address, any changes in their employer’s name
and/or address, or any interruptions of their employment within 10 business days of the change. I
understand these requirements and will notify the UCSD International Center accordingly.
____________________________________
__________________________________ _________________
B) Employers of F-1 students with STEM Extension Optional Practical Training (OPT) authorization are
required to report to the UCSD International Center within 48 hours after the student has been terminated
from, or otherwise leaves, his or her employment with that employer prior to the end of the authorized OPT
period. I understand this requirement and will notify the UCSD International Center accordingly.

____________________________________
__________________________________ _________________ International Center | University of California San Diego | La Jolla, CA 92093-0018 USA | Tel: (858) 534-3730 | Fax: (858)534-0909 | istudents@ucsd.edu | http://istudents.ucsd.edu

Source: https://icenter.ucsd.edu/_files/ispo/f-1/STEMExtOPTApp.pdf

New patient cancellation policy

Allergy Diagnostic and Treatment Center • David K. Brown, MD Christian D. Gonzoph, PA-C • Rebecca A. Rosenberger, PA-C • Kristine M. Cisko, PA-C 33 Overlook Road, Suite # 307, Summit, NJ 07901 Tel . (908) 522-9696/Fax: (908) 522-3070 New Patient Cancellation Policy Welcome to our practice and thank you for choosing us! We appreciate your confidence and

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