Rev. 5/22/08

Curricular Practical Training Cancellation Form Student ID SEVIS #N

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 ___________________________________

University of Northern Virginia 7535 Little River Turnpike, Suite 103, Annandale, Virginia 22003 Phone: (703) 941-0949 Fax: (703) 941-0893-www.unva.edu