Employer Information:
1.
Business/Company/Organization Name: ________________________________________________________
2.
Employer Identification Number (EIN): ________________________________________________________
3.
Your Job Title: _____________________________________________________________________________
4.
Start Date: _________________________ End Date
(of previous employer - if any):
________________________
5.
Full-Time/Part-Time:
Full-time: more than 20 hours per week Part-time: 20 or less hours per week
6.
Work Site Primary Address: _________________________________________________________________
Secondary Address (if any): __________________________________________________________
7.
Explain how this job is related to your course of study (degree):
Supervisor Information:
1.
Supervisor Name: _____________________________________________________________________
2.
Phone Number: ______________________ and/or Email: _______________________________
Acknowledgement Information:
To meet the requirements as an F-1 International Student at Loma Linda University (LLU), I,
, agree that:
Student Given and Family Names
1. I will make sure my employment information, home address, and phone number are current. I
will make any changes and/or additions in my SEVP Portal account or inform International
Student & Scholar Services Office.
I understand that failure to meet any of the above requirements may result in termination of my OPT and
F-1 immigration status at Loma Linda University.
Student Signature
Date ISSS Sign & Date
