Required Information For All Sections

*First and Last Name:

*Email:

*Student ID:

*Major:

Joint Major (if applicable):

(If moved in U.S.) New Address:

U.S. Address:

Suite/Apartment:

City:

State:

Zip Code:

Home Country:

*Telephone Verification:

On Campus Employer:

On-Campus Employer

Department:

Dates of Employment: to

Supervisor:

Off-Campus Employer:

Type of Employment:

F-1 OPT F-1 Ec. Hard

J-1 AT    J-1 Ec. Hard

Dates of Employment: to

Address:

Supervisor's Name:

Contact Number:

Travel or Other Information (SEVP 45 day notice in effect.)

Travel Itineraries (to be submitted prior to travel out of the US) Expected Changes to SEVIS record: (RCL, CPT, OPT, AT, joint degree, financial changes, etc.)