University of Northern Virginia

7535 Little River Turnpike, Suite 103, Annandale, Virginia 22003

Phone: (703) 941-0949 Fax: (703) 941-0893-www.unva.edu

Curricular Practical Training Cancellation Form

SEVIS #N

Student ID

Mr. / Mrs. / Ms.

Student Last (Family) Name

Student First Name

M.I.

I would like to cancel the work authorization for:

Company Name:
Company Address:

Company Phone:

Employment to end date is

Name of Company Contact:

Reason for leaving Job:

I understand that the employer will provide a job evaluation with this form
otherwise I will not be eligible for any further CPT work authorization.

Student Signature

Date

For Office Use Only:

Evaluation attached

Yes

No

Date to submit ______________________

Co-Op Assistant Signature _______________________________________Date ___________________________________

Rev. 5/22/08