OPT EMPLOYMENT REPORTING FORM
Students approved for Optional Practical Training (OPT) are required to report their employer’s name and address and
the start date of employment as soon as they begin working; they must also report termination of employment. They
must continue to report changes in their residential address within 10 days of moving. Students approved for a STEM
extension of OPT have additional reporting obligations. Required information must be submitted to ISO so it may be
updated in SEVIS. Failure to comply will result in termination of the student’s SEVIS record and loss of legal F-1
immigration status.
SECTION I: STUDENT INFORMATION
LAST NAME: _______________________________ FIRST NAME: ______________________ UIN: 81_________________
BIRTHDATE (mm/dd/yyyy):_______________________ SEVIS ID NUMBER: _____________________________________
SECTION II: U.S. ADDRESS AND CONTACT INFORMATION
Enter your current residential address below. You must also update this information (if it has changed) in the FGCU
Office of the Registrar under: Change of Address/Name Change Form at
http://www.fgcu.edu/Registrar/files/Address-
Name_Change_Form_04_2016.pdf
STREET ADDRESS: ___________________________________________________________________________________
CITY: _________________________________ STATE: ______________________________ ZIP CODE: _______________
EMAIL: ____________________________________________________ PHONE: _________________________________
SECTION III: EMPLOYMENT INFORMATION
Select the reason you are submitting this form and then provide your employment details. If you need to report more
information than the space below allows, please provide the items of information requested below for each additional
employer you have worked for in a separate document and submit to ISO or email to Internationalservices@fgcu.edu
I am reporting employment information for the first time. (NOTE: If this is the first time you are submitting this
form, you should report all employment activity since the beginning of your OPT authorization period.)
I am reporting a change in my employment information.
END DATE of employment at former employer, if applicable (mm/dd/yyyy):______________________
I am reporting the addition of a second (or third) employer.
I am participating in the 24-month STEM extension of OPT and am submitting the:
6-month validation report
12-month validation report
International Services
Florida Gulf Coast University
10501 FGCU Blvd, South
Fort Myers, Florida, 33965-6565
P: 239-590-7925 F: 239-590-7977
www.fgcu.edu/international
Employer 1:
NAME OF COMPANY OR INSTITUTION: __________________________________________________________________
NAME OF IMMEDIATE SUPERVISOR: ____________________________________________________________________
SUPERVISOR CONTACT: PHONE NUMBER: (______) ______--_________ E-MAIL ADDRESS: ________________________
COMPANY OR INSTITUTION’S EMPLOYER IDENTIFICATION NUMBER (EIN): ___-- _______________
START DATE (mm/dd/yyyy):______________________ END DATE if applicable (mm/dd/yyyy):_____________________
STREET ADDRESS: ___________________________________________________________________________________
CITY: _________________________________ STATE: ______________________________ ZIP CODE: _______________
JOB TITLE: _____________________________________________ NUMBER OF WORK HOURS PER WEEK: ____________
DESCRIBE HOW YOUR EMPLOYMENT RELATES TO YOUR FGCU DEGREE: ________________________________________
__________________________________________________________________________________________________
Employer 2:
NAME OF COMPANY OR INSTITUTION: __________________________________________________________________
NAME OF IMMEDIATE SUPERVISOR: ____________________________________________________________________
SUPERVISOR CONTACT: PHONE NUMBER: (______) ______--_________ E-MAIL ADDRESS: ________________________
COMPANY OR INSTITUTION’S EMPLOYER IDENTIFICATION NUMBER (EIN): ___-- ________________
START DATE (mm/dd/yyyy):______________________ END DATE if applicable (mm/dd/yyyy):_____________________
STREET ADDRESS: ___________________________________________________________________________________
CITY: _________________________________ STATE: ______________________________ ZIP CODE: _______________
JOB TITLE: _____________________________________________ NUMBER OF WORK HOURS PER WEEK: ____________
DESCRIBE HOW YOUR EMPLOYMENT RELATES TO YOUR FGCU DEGREE: ________________________________________
__________________________________________________________________________________________________
SECTION IV: NEW FORM I-20 REQUEST (optional)
Issuance of a new I-20 is not required but is recommended for international travel or for use in benefit applications
at governmental offices such as the DMV or Social Security Administration. Select one of the options below.
I am NOT requesting a new Form I-20 at this time.
I am requesting an updated Form I-20 reflecting my current employment information and would prefer
the following:
I will pick up the I-20 at ISO once it is ready.
I will have the following friend or relative pick up the I-20 at ISO: ________________________________
I would like the I-20 to be sent via regular mail to my Immigration Reporting Address (stated above).
Signature: ___________________________________ Date: ______________________
click to sign
signature
click to edit
Chrome Web Store
It looks like you haven't installed the Fill Chrome Extension Add to Chrome