Fillable Curricular Practical Training (CPT) Form (Loma Linda University)

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Curricular Practical Training (CPT) Form (Loma Linda University)

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The Curricular Practical Training (CPT) Form (Loma Linda University) form is 3 pages long and contains:

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  • 0 check-boxes
  • 131 other fields

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File type: PDF

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Curricular Practical Training (CPT) Form
1
Student Information:
Family Name:
Given Name:
LLU ID #:
Email Address:
CPT Information: (Additional Sites on Page 3)
Couse Number:
Course Name:
Site Name
Site Address
(Street # and Name, City, State,
Start Date
End Date
Number of Hours
(per week)
Couse Number:
Course Name:
Site Name
Site Address
(Street # and Name, City, State,
Start Date
End Date
Number of Hours
(per week)
Student Acknowledgement:
To meet the requirements as an F-1 International Student at Loma Linda University (LLU),
I, ____________________________________________________________________, agree that:
Student Given Name and Family Name
1. I deem the information above as correct to the best of my knowledge.
2. I will notify the International Student & Scholar Services office if there are any changes in my
CPT listed above or if I have any additional sites off campus to report.
3. The above information pertains to a curricular requirement for me to complete my current
program/degree, and not for personal gain.
4. Working full-time, if applicable, under CPT affects my eligibility for a full-term (12 months) of
Optional Practical Training (OPT).
I understand that failure to meet any of the above requirements may result in termination of my
I-20 and F-1 immigration status at Loma Linda University.
______________________________________________ _______________ ______________
Student Signature Date ISSS Advisor
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signature
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Curricular Practical Training (CPT) Form
2
School/Department Acknowledgement
By signing below, I agree to the following:
▪ I acknowledge that the student and rotation site information are correct, and that the above
activity is a curricular requirement for the student’s program/degree.
▪ I agree that I will notify the International Student & Scholar Services office with any changes
pertaining to the student’s site information above.
▪ I understand that students who work full time (20-40 hours a week) under CPT become
ineligible for a full 12 months of Optional Practical Training (Part-time CPT does not effect a
student’s eligibility for a full 12-month term of OPT).
▪ I understand that falsified information can result in legal consequences, including termination
of the student’s F-1 immigration status at Loma Linda University.
_______________________________________________
Print Name (Academic Advisor or Department/Program Chair)
_________________________________________ ________ _________________________
Department Extension Email
_________________________________________ _____________
Signature Date
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signature
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Curricular Practical Training (CPT) Form
3
CPT Information: Additional Sites
Couse Number:
Course Name:
Site Name
Site Address
(Street # and Name, City, State,
Start Date
End Date
Number of Hours
(per week)
Couse Number:
Course Name:
Site Name
Site Address
(Street # and Name, City, State,
Start Date
End Date
Number of Hours
(per week)
Couse Number:
Course Name:
Site Name
Site Address
(Street # and Name, City, State,
Start Date
End Date
Number of Hours
(per week)
Couse Number:
Course Name:
Site Name
Site Address
(Street # and Name, City, State,
Start Date
End Date
Number of Hours
(per week)
Couse Number:
Course Name:
Site Name
Site Address
(Street # and Name, City, State,
Start Date
End Date
Number of Hours
(per week)
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Curricular Practical Training (CPT) Form (Loma Linda University)

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Completed 22 August 2020

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