Request For Cpt-Semester Internship Form
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3Request for CPT—Semester Internship
STUDENT SECTION (to be filled out online)
Name ______________________________________________ UIN _________________________ SEVIS ID# N___________________________
SEVIS U.S. Address _______________________________________________________________________________________________________
E‐Mail:____________@odu.edu Level:
Bachelors
Masters
Ph.D. Major _____________________ Is this correct on I-20?
Yes
No
This is
my graduating semester
a summer semester
fall or spring but not my graduating semester
MASTERS & PH.D. STUDENTS: Do you currently have a graduate assistantship? Yes No
ON-CAMPUS EMPLOYMENT: Do you currently have on-campus employment (NOT an assistantship)? Yes No: If Yes, hours per week?______
INTERNSHIP INFORMATION
Requested CPT Dates (MM/DD/YYYY) ______________ - ______________ This CPT is
full-time (+ 20 hrs/week)
part-time (1-20 hrs/week)
What are the SPECIFIC goals of this particular internship? (NOTE: “To obtain practical experience in the field (or the like)” is not an acceptable goal.
Please indicate goals relevant to coursework and/or duties in internship.)
1.
2.
Supervisor’s Name______________________________________ Phone _______________________ E-Mail _______________________________
I understand that I am responsible for maintaining my F-1 status as detailed in the CPT workshop, on the ISSlist-l listserv, on the CPT Responsibilities
Form and/or on the ISSS web site.
Signature ______________________________________________________________________________ Date____________________________
DEPARTMENT SECTION (to be completed by either a GPD or a Chief Departmental Advisor)
Is this a bona fide internship
This internship is
required of ALL students in this department (not elective credits).
that is directly related to this
optional (elective) credit that WILL be directly applied to the student’s credit for graduation.
student’s coursework and/or
optional (elective) credit that WILL NOT be directly applied to the student’s credit for graduation.
academic program?
Anticipated Semester of Graduation
May
August
December Year ________________
Yes
No
Which of the following remain in the student’s program?: coursework
project
exam
thesis/dissertation
I verify that the above-provided internship goals are in keeping with an integral part of the degree program and that I have communicated about them with the student
and/or the student’s advisor.
Signature ___________________________________________________________________ Date _________________________________
Name____________________________________________ Extension___________________ E-Mail_______________________@odu.edu
Relationship to student:
Graduate Program Director
Chief Departmental Academic Advisor (undergraduates only)
CAREER MANAGEMENT CENTER SECTION
I have reviewed the internship and goals outlined above and have discussed the requirements with the student. I recommend you authorize this
student to participate in the CPT as described. The student has been registered for the following course: ____________________________
Name ________________________________ Signature _____________________________________________ Date __________________
Holds? __Yes __No
If “yes,” type? ________________________
GPA ______ Registered for CPT? __Yes __No
If in graduating semester, also registered for other credit? __Yes __No Addresses match in: __SEVIS __Banner __Atlas
ISSS
Workshop? __Yes __No Assistantship on I-20 Finances? __Yes __No
Processing
Letter: __Letterhead __Original __Company address __ Hours/week __Start/End Dates __Duties __Internship only __Hourly pay
Only
NOTES:
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