ࡱ> #` _bjbj p &00081|1 F.255557b94.;EEEEEEE$Gh8JpEu>v7v7">>E55\FAAA>p55EA>EAAA52 ͓0m?|ABrF0FAJ?JAA"JB;N<^A<L<;;;EEAX;;;F>>>> $ \F Biographical Information 1. Today s Date (mm/dd/yyyy):  FORMTEXT       2. Full Name as noted on passport :  FORMTEXT       FORMTEXT       FORMTEXT        Last First Middle3. SU ID: FORMTEXT      4. SEVIS #:N  FORMTEXT      5. Country of Citizenship: FORMTEXT      Contact Information6. Current Phone:   FORMTEXT       7. Current E-mail Address:   FORMTEXT       8. U.S. Address:  FORMTEXT        FORMTEXT        FORMCHECKBOX  Residential  FORMCHECKBOX  Mailing 9. For I-20 Mailing: U.S. Mailing Address (if different than above):  FORMTEXT        FORMTEXT      10: Mailing Preference:   FORMCHECKBOX  Standard Mail  FORMCHECKBOX  Courier Service provide credit card account # and expiration date.  FORMTEXT        FORMTEXT       Academic Program of Study11. Institution:  FORMCHECKBOX  Syracuse University  FORMCHECKBOX  SUNY ESF12. Degree Level:  FORMCHECKBOX  Bachelors  FORMCHECKBOX  Masters  FORMCHECKBOX  Ph.D.13. Academic Major(s):   FORMTEXT       14. CIP code (if known) FORMTEXT       Optional Practical Training Information15.Current EAD End Date (mm/dd/yyyy): FORMTEXT       16. How many days of unemployment have you accrued during your initial OPT EAD authorization period?  FORMTEXT       17. Have you maintained valid F-1 status while on OPT?  FORMCHECKBOX  Yes  FORMCHECKBOX  No 18. Have reported all changes of name, address, employers, and interruptions of employment to the Slutzker Center?  FORMCHECKBOX  Yes  FORMCHECKBOX  NoCurrent Employer Information19. 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Is your employer registered with E-Verify? FORMCHECKBOX  Yes  FORMCHECKBOX  No25: I attest that I understand the criteria for maintaining F-1 status while engaging in OPT and that the information I provided above and the documentation I submitted with my STEM Extension Request is true and valid. FORMCHECKBOX  Yes  FORMCHECKBOX  No  SignatureDate (SCIS Advisor Use ONLY)STEM OPT Extension Document Review  FORMCHECKBOX  Copy of I-765  FORMCHECKBOX  Copy of current EAD card and any previously issued EAD cards  FORMCHECKBOX  Copies: passport, visa, I-94 (front & back) , health insurance  FORMCHECKBOX  STEM Student Responsibility Checklist  FORMCHECKBOX  Copy of transcript or diploma  FORMCHECKBOX  Employer statement- relationship of STEM field to job  FORMCHECKBOX  Mailing information (and payment details if applicable)  FORMCHECKBOX  Maintained F-1 Status  FORMCHECKBOX  Reported Changes in Address, Name, Email, & Employment  FORMCHECKBOX  Did not Accrue more than 90 days of unemployment  FORMCHECKBOX  Qualifying CIP Code and STEM degree program  FORMCHECKBOX  Employer part of E-Verify Notes Advisor s Initials:Date Received:Pick-Up Date:     STEM Extension Data Sheet Lillian and Emanuel Slutzker Center for International Services Division of Student Affairs 310 Walnut Place |Syracuse, New York 13244-2380 TEL: 315-443-2457 | FAX: 315-443-3091 EMAIL:  HYPERLINK "mailto:lescis@syr.edu" lescis@syr.edu BRDRnRRS.SXSaWWWWW $If]kd;#$$IfTlE\.+b $  0+4 laTS S"S$S.S0SLSNSPSVSXSZSTTUU UU@UJULUhUjUlUrUtUvUzU|U~UUUUUUUVDžyspldCJ\]aJh[=aJ h[=aJ6CJOJQJ^JaJ6CJOJQJ^JaJh: V56CJaJjU'5CJUaJj&5CJUaJ5CJ^JaJ CJ^JaJh: V6CJaJ5jI%5CJUaJj5CJUaJj$5CJUaJ 5CJaJ%XSZSHTUJUtUaWWWW $If]kd%$$IfTlE\6%+ 0+4 laTtUvUxUzU$Ifwkd'$$IfTlE0%+ &0+4 laTzU|U~UUU$Ifdkd($$IfTlF++0+4 laTUUU$IfwkdI)$$IfTlF0+ 0+4 laTUUV $$Ifa$kkd)$$IfTl}++0+4 lap TVVV8VVVXVZV^V`V|V~VVVVVVVV>W@WBW^W`WbWdWfW~WWWWɺn`Kn```)j,hCJOJQJU^JaJhCJOJQJ^JaJ#jhCJOJQJU^JaJ#j,CJOJQJU^JaJCJOJQJ^JaJ#j,CJOJQJU^JaJCJOJQJ^JaJjCJOJQJU^JaJ5CJOJQJ^JaJ5CJOJQJ\]^JaJ5CJOJQJ^JaJh: V6CJaJ 5CJaJVVXV $$Ifa$tkd*$$IfTlF++  +0+4 lap +TXVZV\V^VVV>W@WWWVXXXXXJYLY$Iftkd[+$$IfTl++  0+4 lap TWWWXXXXXRXVXXXZXvXxXzX|XXXXXXXXHYJYLYNYjYlYnYYYYZյյՠյzo]#j.CJOJQJU^JaJCJOJQJ^JaJCJaJ#j.CJOJQJU^JaJjCJOJQJU^JaJ)j-hCJOJQJU^JaJCJOJQJ^JaJ)j^-hCJOJQJU^JaJhCJOJQJ^JaJ#jhCJOJQJU^JaJCJOJQJ^JaJ!LYYY2Z4ZZZP[R[[[*\,\.\vkd,1$$IfTl 0|+0+4 lapT$If ZZZ2Z4Z6ZRZTZVZZZZZZZP[R[T[p[r[t[v[[[[[[[*\,\ӶȤȤlZUCJaJ#j0CJOJQJU^JaJ)jV0hCJOJQJU^JaJ)j/hCJOJQJU^JaJhCJOJQJ^JaJ#jhCJOJQJU^JaJ#j/CJOJQJU^JaJCJOJQJ^JaJCJOJQJ^JaJjCJOJQJU^JaJ#j /CJOJQJU^JaJ,\.\8\:\<\B\D\F\j\n\p\\\\\\\\\\\\\\\\\\]]~]]]ʼwmaY:OJQJ^J5:CJOJQJ^J5:OJQJ^J&j5:OJQJU^JmHnHu5:CJ$OJQJ^JaJ$hb35:CJaJ jU5CJ^JaJhr5CJ^JaJhrCJOJQJ^JaJCJOJQJ^JaJhVOh: V6CJaJh$CJ\]aJCJ\]aJh: V56CJaJ .\:\<\>\@\B\D\xxxx $If]tkd#2$$IfTl ++  0+4 lap T $$Ifa$D\F\n\p\\\\\ $If]$Ifdkd2$$IfTlu++0+4 laT\\\\\\\;99999kdr3$$IfTlpֈkW"+ctpTu 0+4 laT\\\\\\\]<]]],^|^^zzzztth^hhd^h<$@i1&#$$d %d &d 'd +D-D/M %N O P Q a$>dx@i1&#$$d %d &d 'd +D-D/M %N O P Q  ],^^^^^^^^^^_ٶCJ OJQJaJ mH sH 0JCJOJQJ^JmH sH 'jx4CJOJQJU^JmH sH !jCJOJQJU^JmH sH CJOJQJ^JmH sH CJOJQJ^J ^^^^_h^h,1h/ =!"#$%h n {\&rf9ys}c׾ZҚ=G|d^_Mz=/kO1D .XĆ:#p|X~ȍL"Gj#6G)8y0{ˁk$荁{\Z򕊲/N-\I'[ˆ|E}̳McfcfM] +*Bؙ~μI9zhn UV؉ۦ(sۉAI20 i8Gp6=mk$bTg}2Tw‚c]0n%c y!>ft'ڇƣO>Y P3Kh(50yaNLN=oJ+P5_ 8IoMD7+ѵg d# r۷I:2eriG|J.3 mraR(.)Oq^ msFխfI|f@Z*M^S" "$N[17R1|e\WܙTnͳG)C3Z1\jV:d,­μOU6J y+2թJdow8q/\U79goA[AsR]-DL6RX~ƁfY,zFkDꀘhS;&se)+9*JR-K|CC/=dM,:f܈I8Y{ղ_>?n  SI:<D8_`P4ۛKSBu)\4J9GÉc/-? : bƜ QpPiU(N%öѩHH5ޙz-/xlʹS{FnOgXdT;(wfآo*^Zf%TeUYiB_RS `'q,-[~ںqi2;hz%Q7[e7D儫R2Ҩx>L:_3pd n8tn .+bJD}H(u8ǐؓ⸼ϒe t-qf4#p5٪;Lci& FJd0Zh!ļ,nC_(A.4 Qu95S1pM=A_W9wX|eX1MR7ew蓱pU!_%ٓJ5m|eqТ}S Е˰ c56a g'|#).ODxտՄi5:0򀓯iՄ_^Jص1p֏1O+[։'Jy.>,.-jc\;'QhqJtУ)Nfݤ%iugu-N܅T`UKOr=vve"qτZ8e +Q5Mk4 3؛MћK H(;E.X"3Ew,\r`$Bes%wm%dRFŖ, ?tf'#ԈomǜQƳIwjKwex㽼0=-yF^yR-)O)iM3<"-.D8*; 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