06/09 EG
International Student & Scholar Services
I(First, Last name) ______________________________, Born on(mm/dd/yr)____________,
Verify that my intended program completion date of,___________________, is the date that I will be
done with all the requirements for my degree and is the same date indicated on the letter from my
department. I have been informed that if no legal action has been taken by me or on my behalf, I will
need to leave the United States within 14 months from this date (after my opt has been granted). I
understand that if for any reason I fail to complete my studies by this date I am required to notify ISSS
(International Student & Scholar Services) and I will have to comply with all the necessary steps needed
to be taken.
I hereby acknowledge my responsibility to bring my EAD (Employment Authorization Document), as
soon as I have received it to the ISSS Office for a copy.
I will report my employer name and address to this office and continue to report any changes made to my
employer information while in active OPT status.
I acknowledge that I am responsible to notify this office, on immigration form AR-11, of any change of
address within 10 days of my move.
I further acknowledge that if I travel out of the United States and I lack any of the following documents, I
most likely will be denied re-entry to the U.S.
A valid signature on my I-20 (Each signature is only valid for 6 months)
EAD (OPT Card)
A letter confirming an on going employment or verifying a guaranteed employment upon return
Valid F1 visa
Signature: ________________________________ Date:________________
Email (not LLU): ______________________________ Phone: ______________
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