106 Bradley International Hall
417 Charles E. Young Drive West
Los Angeles, CA 90095-1379
310-825-1681
CURRICULAR PRACTICAL TRAINING (CPT) REQUEST FORM
Last Name: _____________________________________ Given Name: ___________________________________
(as appears on passport) (as appears on passport)
UCLA ID#: _____________________________________ SEVIS ID#: N____________________________________
Country of
Major: _____________________________________ Citizenship: ____________________________________
Degree Objective: Bachelor’s Master’s Doctorate Email: ____________________________________
Degree Start Term: _______________________________ Anticipated Degree End Term: _____________________
CPT APPLICATION CHECKLIST (submit via email to dcissf1unit@saonet.ucla.edu) Processing timeline 10 business days
I have an internship/employment offer letter on company letterhead that includes start date, end date, number of
hours per week, and signature from the employer.
I have an internship/employment offer letter that includes a description of job duties demonstrating direct connection
to my major and degree level.
I am enrolled and will remain enrolled in an internship course during the term the CPT work authorization will occur.
My CPT internship course is_________________________. If applicable, I have provided a support letter from my
graduate academic department to waive the CPT course enrollment requirement (please see the CPT Guidelines for
Graduate Students for eligibility).
I have completed the CPT Request Form, Explanation, and signed the Certification (pages 1 and 2 of this form)
CPT EMPLOYMENT INFORMATION (If summer CPT, summer fees must be paid)
CPT Term: Fall Winter Spring Summer
Start Date: ___________________________ End Date: __________________________________
Hours per Week: Part-Time CPT (20 hours or less per week) Full-Time CPT (more than 20 hours per week)
Company Name: ______________________________________________________________________________
Company Address: Street Address__________________________________________________________________
City________________________________ State_______________ Zip Code_______________
FOR OFFICE USE ONLY
INIT: ___________ DATE: _____________________
□ Restriction Holds
□ Current Enrollment
□ Past Enrollment
□ Current I-20
106 Bradley International Hall
417 Charles E. Young Drive West
Los Angeles, CA 90095-1379
310-825-1681
CPT EXPLANATION AND CERTIFICATION
Student’s Name: _______________________________________ UCLA ID#: _________________________
F-1 visa regulations require that a practical training opportunity be directly related to the student’s major area of
study. Explain in 3-5 sentences how your employment/internship, as described in your employment/internship
offer letter, is directly related to your major field of study:
CERTIFICATION:
I have read and understand the eligibility requirements and work restrictions of CPT. I certify that my practical
training opportunity is directly related to my major field of study and have provided an accurate description of
how my employment/internship is directly related to my major field of study. I will notify an F-1 Counselor at the
Dashew Center immediately regarding any changes or deviations from the offer letter or explanation provided
above regarding my CPT opportunity. I understand that if I drop or do not complete the individual
studies/internship course required for CPT authorization during this term, my CPT authorization will be
revoked, and I will be in violation of my F-1 status.
Signature: ____________________________________________ Date: _____________________________
SOCIAL SECURITY NUMBER
A Social Security Number (SSN) is required to receive wages, file taxes, and receive some types of government
services in the United States.
If your CPT has been approved by the Dashew Center and you do not have a SSN, please request a Social
Security Support Letter before applying for a SSN from your local Social Security Administration (SSA) office.
Students who already have an SSN do not need to apply for a new SSN.
The earliest you can apply for a Social Security Number is 30 days before your CPT internship/employment start
date. For more information about applying for an SSN, please review the ‘Social Security Letter’ tab on the
Dashew Center website.
