TorequestaSTEM extensionI-20you MUSTsubmitall of the followingvia email to: .
1.Request for STEM OPT EXTENSION Form
2.AttestationForm(keep a copy for your record.
3.A photocopy/scan ofyour currentEAD card
Name:
(Family/Last)(First/Given)
Dateofbirth: / / Email: ______@______
(mm/did/yyyy)
USPhoneNumber: ______CurrentEADExpirationDate: / /
BMCDegree/Major/s(mostrecent):/
Yourresidentialaddress:
City:
State:
ZipCode:
Be mindfulofspelling/capitalization/punctuation.Datawill appearinSEVISexactly asyou enterit below.
EmployerName: ______
EmployerAddress: ______
City: ______State: ______Zip Code: ______
E-VerifyNumber(usually4-6digits): ______Employer’sEINNumber: ______-______
(NOTE:ThisisnotthesameastheE-verifynumber.TheEmployerIdentificationNumber(EIN)isanumberassignedtoeveryemployerby the USInternalRevenueService(IRS).ItisapublicnumberanditappearsonIRSwithholdingforms.TheEINwill appearonthe employee’sFormW-2inFieldb.)
Myemploymentis:FullTime(morethan20hoursperweek)PartTime(20orlesshoursperweek)
JobTitle: ______EmploymentStartDate: / /
SupervisorName: ______Supervisor Title: ______
SupervisorPhone: ______SupervisorEmail:
Explain howthe employment is related toyourMAJORfield of study.
(Note:This is arequiredfieldin SEVIS.Studentswhowork inan unrelatedfieldfail tocomply withthe federalregulations. Ifthe Department ofHomelandSecurityidentifies thatyourwork is notdirectlyrelatedtoyourmajorfieldofstudy,your SEVISrecordcould be terminatedforfailing tomaintainstatus. Therefore,make sureyou are clear inhowthe job directlyrelates toyourmajorfield. Itis also important that youkeepcomplete recordsofallemployment duringtheOPTperiod –job offerletters,jobdescription,paystubs,etc. Thisway, shouldyouever be askedtoshowthis informationinthe future,youwillhave it.)
(maximum1000characters)
□ Iwillpick up theI-20fromthe Pensby Center, BMC
□ I chooseeShipGlobalfor expressmailing(FedEx/UPS)and will create a shipping label at:
□Bycheckingthis box, I certifyall informationis accurateandcompletetothebestofmyknowledgeand Irequest that issuea STEMOPTI-20.I alsoconfirmthat afterreceivingmySTEMOPTI-20, Iwill adheretotheguidelines intheAttestationandwill thenapplytoUSCISfor theSTEMExtensionina timely manner asI understandthat USCIShas strictfilingdeadlines.
SIGNATURE: ______DATE:______/______/______
05/16