Termination of Employment Report

Termination of Employment Report

This form must be given to an employer if you the F-1 student are working on a 17-month STEM OPT extension.

You have hired one of our former international students for the 17-month STEM OPT Extension. The Department of Homeland Security requires that you report to our office if the employee’s job is terminated either by you (the employer), the employee, or the employee has not shown up to work unexplained for five days. Should this happen, please fill out this form and return it to the International Services for Students and Scholars Office within 10 days of termination. Thank you for your assistance.

Employer/Company Name:_________________________________________________

Supervisor Name:_________________________________________________________

Employer Address:________________________________________________________

_______________________________________________________________________

Employee Name:__________________________________________________________

Date of Hire:_____________________________________________________________

Date of Termination:_______________________________________________________

Reason for Termination:____________________________________________________

_______________________________________________________________________

I certify that the above information is true and correct

Date: _______________Signature____________________________________________

Please return to:

International Services for Students and Scholars

Rensselaer Polytechnic Institute

Academy Hall Room 4600

110 8th Street

Troy, NY 12180

5/08

Last modified: May 13, 2008
International Services for Students and Scholars, Phone: (518) 276-6561, Fax: (518) 276-4839