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Using an outdated form will result in your OPT application being returned or rejected.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