SAMPLE I765 Form — STEM OPT Applicaons (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 Using an outdated form will result in your OPT applicaon being returned or rejected.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]