SAMPLE I765 Form — STEM OPT Applications (2 pages) Use this sample to help guide you when you fill out the I-765. The IO advisor will go over the form with you when you apply for OPT. Always download and use the most recent I‐765 directly from www.usics.gov.

Using an outdated form will result in your OPT application being returned or rejected.

***PRINT SINGLE-SIDED***

Mark for STEM

Extension OPT

#2 and #3

This is the address

where your EAD

card will be sent. If

you will be moving

or traveling, we

HIGHLY

recommend you use

the IO address.

#10

Retrieve your I-94

Number at

cbp.gov/i94

#11

Indicate “Yes”

USCIS OFFICES:

YSC-Potomac

LIN-Nebraska

WAC-California

EAC-Vermont

SRC-Texas

MSC-Missouri

[Refer to EAD Card] [EAD Dates]

C 3 B

#16

(C) (3) (C) for

STEM Extension

OPT

Last Updated 1/2017

Page 1/2

C 3 C

[Refer to EAD Card] [OPT Dates]

#17

Degree: Bachelors,

Masters, or PhD

Ask Employer for

Name and

E-Verify Number

DON’T

FORGET TO

SIGN, Date, &

Include Phone #!

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