OPT Information Verification Form (all fields are required)
Personal Information
Current Employment Information
Past Employers: (Please list all past OPT employment along with start and end dates of work)
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
Have you changed your visa status? ________ If so, to what status? __________
___________________________ __________________________
Signature Date
Please check the blank below if the statement applies to your situation:
________ I have returned to my home country and will not be completing my OPT. If you check this blank, your
I-20 will be completed. Please contact us if you do plan to return to the U.S. on OPT.
Name of Employer: ______________________________________
Address of Employer (this is your physical work address):
______________________________________________________________________
Street Address
______________________________________________________________________
City State Zip Code
Start Date: ___________ Job Title: ______________ Full or Part time: __________
Brief Job Description: ___________________________________________________
______________________________________________________________________
Name of Supervisor: ___________________ Telephone of Supervisor: ____________
Email of Supervisor: ___________________________
Name: ___________________________________ Tech ID: ___________________
Current Residential Street Address:
________________________________________________________________________
Street Address
________________________________________________________________________
City State Zip Code
Current E-mail Address: __________________ Cellphone Number: _______________
