Maryville University OPT Reporting Form

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Student Information

Last Name

First Name

Degree Program/Major

OPT Employment Information

Employer Name

Employer Address

Start Date

End Date

Employer Identification Number (EIN), if available

Full or Part Time

Full TimePart Time

Number of hours per week

Job Title

Job Responsibilities

Brief explanation of how this position is related to your major field of study

Supervisor Name

Supervisor Phone Number

Supervisor Email