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OPT Employer Information

Personal Information

First Name

Last Name

Date of Birth (MM/DD/YYY)

Home Address

Home City

Home State

Zip Code

Home Telephone

Non-Vanderbilt E-mail Address

Current Employer Information

(If Vanderbilt University is current employer Company Name should be listed as Vanderbilt, Department of __________, and Company Address should be Department's physical location.)

Situation (Check One)
 Employed - Enter Employment Start Date Below Change to New Job (less than 10 days between jobs) - Enter Start Date of New Employment Unemployed (more than 10 days) - Enter Previous Employment End Date Below Decided to Leave the U.S. and not use OPT - F-1 record will be closed

Employment Start Date

Previous Employment End Date

Company Name

Company Address

Company City

Company State

Company Zip Code

Dates of Interrupted Employment (Dates when you were not employed, if any)

Other Comments (reasons for unemployment, if any)