OPT Date Verification Form

OPTIONAL PRACTICAL TRAINING (OPT) DATE VERIFICATION FORM
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Please enter your surname and given name as they appear on your Form I-20.
Surname: ______________________________________________________ Given Name: ___________________________________________________

Residential Street Address: ______________________________________________________________________________________ Apt. #: _______

City: ________________________________________________State: ____________________________________________ Zip Code: _________________

Primary E-mail Address (the one you will use after graduation):_____________________________________________________________

SEVIS # (Listed on the top right corner of your Form I-20): N _____ _____ _____ _____ _____ _____ _____ _____ ______ _____

I-20 Completion Date (section #5 on your Form I-20): ______________________________________________________________________

Current Major or Field of Study (if different than section # 5 on Form I-20): _______________________________________________

Employer Name (write employer name and address below if you have secured a job):

Employer Name: ________________________________________________________________________________________________________________

Employer Address: _____________________________________________________________________________________________________________

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Will you be employed by Harvard University, even if only temporarily: Yes: _____ No: _____ If yes, list the following:
Department/Institute/Center Name: ______________________________________________

Faculty/P.I./Director Name ______________________________________________

Requested dates of OPT: ______/______/__________ until ______/______/__________
(mm/dd/yyyy)
(mm/dd/yyyy)

 Part-Time Pre-Completion OPT
 Full-Time Pre-Completion OPT
 Full-Time Post-completion OPT
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In signing this form I acknowledge that I will do the following to abide by the OPT reporting requirements:
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Will only engage in employment in the field of study and the degree on which this OPT application is based
Will report to the HIO any changes in employers
Will report to the HIO any changes in my address (where I physically reside) within ten days of a change
Will report to the HIO any changes in my or my dependent’s name(s)
Will report to the HIO any change of my immigration status (e.g. F to H or J, etc.)

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Signature

______________________________________________
Date

For office use only:
Pre-completion: ________

Post-completion: _________

End date _______/_______/_______
Do not change Start date

Harvard International Office * Richard A. and Susan F. Smith Campus Center * 1350 Massachusetts Avenue, Room 864
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617-495-0640 W

www.hio.harvard.edu