17-Month (STEM) Extension Report and Validation Form

17-Month STEM Extension Report (ANd VAlidation) Form

While on your STEM-Extension OPT, the Department of Homeland Security requires that you fill out this report every 6 months from the start date on your STEM-Extension EAD card.  After submitting, make sure to print a copy of the Form Handler Confirmation Page as proof of your report.  Due to high demand, IPS is unable to respond to personal requests for confirmation.

* Indicates a required field.

To:		International Programs & Services
From:
*Today’s Date:
*SJSU Student ID #:
*Last/Family Name:
*First/Given Name:
*Current Address:
* Email:
*SEVIS ID #:
*Name of Current Employer:
*Employer’s Address:
*Name of Supervisor:
*Employer Phone #:
*Employment Start Date:
* Employment End Date (Indicate “on-going” if currently employed):
*Have there been any changes in the above information in the last 6 months?:		Yes   No
*If yes, please explain:

Be sure to provide IPS with a copy of your current STEM Extension EAD, if you have not done so. 

 I certify that the above information is true and correct.