Issis.uga.edu

The 17-Month Extension applies to students in STEM (Science, Technology, Engineering, and Math) fields. Please read and complete the following form and
International Student, Scholar, and Immigration Services (ISSIS) will process your application accordingly.
IMPORTANT: *Your employer for the 17-Month Extension MUST be a participant in E-Verify.
Go to http://www.dhs.gov/ximgtn/programs/gc_1185221678150.shtm to verify a participating employer. *To find specific majors that qualify for the 17-Month Extension, please visit http://www.ice.gov/sevis/stemlist.htm * While on the 17-Month Extension, you are required by federal regulation to submit updated biographical (address, name changes, etc) to ISSIS once every six months (even if there is no change) by email opt@uga.edu
Part I. Personal Information
Student’s Last Name___________________________ First Name___________________________ Middle Name___________________________ Current Address________________________________________________________________________ Date of Birth ____________________ Degree & Major ___________________________________ Date Degree Awarded ____________________ Department ___________________ Phone Number _______________________ Cell Phone Number _____________________ Current Email Address _________________________ UGA ID _____________________ SEVIS ID N000_____________________ OPT Start Date ________________ OPT End Date ____________ Part II. Past Employment
Your employment since you completed your degree at the University of Georgia. Please also indicate any unemployment period, if applicable. Provide total number of days of
Your current employer’s name as listed in
E-Verify company ID number:
unemployment you have accrued since
E-Verify:
(normally 5 or 6 digit number)
your OPT start date on your EAD Card:

Part III. Instructions
If your total number of days of unemployment is more than 90 days since the initial post-completion authorization, you have not properly maintained your status and ISSIS will not recommend you for any further employment. By signing below, I confirm that I am aware of my responsibilities for maintaining status while on OPT. Once ISSIS receives your signed application and materials, ISSIS will check/update your SEVIS status and verify if your major is one of the STEM majors by comparing your CIP code with STEM CIP code listed at http://edocket.access.gpo.gov/2008/pdf/E8-7427.pdf. If it is, ISSIS will make the recommendation by generating a 17-Month Extension Form I-20 and mail it to you. You will have to mail all of the following documents to USCIS directly. You can find out the correct filing address at http://www.uscis.gov/. A check or money order for $380.00 payable to the Department of Homeland Security Download and complete, if you wish to receive electronic notification from USCIS Be sure the answer to question 16 on form I-765 is (c)(3)(C)
A copy of your transcript and degree certificate Photo copy of form I-94 (front and back) 10. Two U.S. passport-style photos (print your name on back of photo) 11. A copy of your previously approved OPT card (both sides) Note: You may find the numerical CIP Code for your degree at http://www.ice.gov/sevis/stemlist.htm to answer item #17 of form I-765. In addition,
CIS new guidance states that a 17-Month Extension can only be filed up to 120 days before post-completion OPT ends. However, USCIS must
receive your 17-month extension application before your current OPT EAD expires.
Signature:
Phone: (706) 542-2900 Fax: (706) 583-0123 Web: www.issis.uga.edu Email: visahelp@uga.edu I-765, Application For
Department of Homeland Security
U.S. Citizenship and Immigration Services Employment Authorization
Do not write in this block.
Application Approved. Employment Authorized / Extended (Circle One) Failed to establish eligibility under 8 CFR 274a.12 (a) or (c). Failed to establish economic necessity as required in 8 CFR 274a.12(c)(14), (18) and 8 CFR 214.2(f) Replacement (of lost employment authorization document). Renewal of my permission to accept employment (attach previous employment authorization document). 1. Name (Family Name in CAPS) (First)
2. Other Names Used (include Maiden Name)
Results (Granted or Denied - attach all documentation) 3. Address in the United States (Number and Street)
12. Date of Last Entry into the U.S. (mm/dd/yyyy)
13. Place of Last Entry into the U.S.
4. Country of Citizenship/Nationality
14. Manner of Last Entry (Visitor, Student, etc.)
5. Place of Birth (Town or City) (State/Province)
15. Current Immigration Status (Visitor, Student, etc.)
16. Go to Part 2 of the Instructions, Eligibility Categories. In the space below,
6. Date of Birth (mm/dd/yyyy)
7. Gender
place the letter and number of the category you selected from the instructions (For example, (a)(8), (c)(17)(iii), etc.).
8. Marital Status
9. Social Security Number (include all numbers you have ever used) (if any)
17. If you entered the Eligibility Category, (c)(3)(C), in item 16 above, list your
degree, your employer's name as listed in E-Verfy, and your employer's E- Verify Company Identification Number or a valid E-Verify Client Company 10. Alien Registration Number (A-Number) or I-94 Number (if any)
Identification Number in the space below.
11. Have you ever before applied for employment authorization from USCIS?
Employer's E-Verify Company Identification Number or a valid E-Verify Certification
Your Certification: I certify, under penalty of perjury under the laws of the United States of America, that the foregoing is true and
correct. Furthermore, I authorize the release of any information that U.S. Citizenship and Immigration Services needs to determine eligibility for the benefit I am seeking. I have read the Instructions in Part 2 and have identified the appropriate eligibility category in
Block 16.
Signature of Person Preparing Form, If Other Than Above: I declare that this document was prepared by me at the
request of the applicant and is based on all information of which I have any knowledge.

Source: http://www.issis.uga.edu/images/docs/employment/opt_application_stem_c3c.pdf