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    ssn-form

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    Bhagyashree Modi

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    © All Rights Reserved
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    ssn-form

    Uploaded by

    Bhagyashree Modi
    3 views2 pages

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    Copyright:

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    3 views2 pages

    ssn-form

    Uploaded by

    Bhagyashree Modi

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
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    of 2

    5000 Forbes Ave, Cyert Hall Suite 101, Pittsburgh, PA 15213

    Email: [email protected] ▪ Web: www.cmu.edu/oie ▪ Phone: (412) 268-5231

    OIE Student/Scholar Request for Services


    For processing purposes, please print these forms single sided (2 separate sheets of paper)

    Surname/Family Name: Given/First Name:

    Andrew e-mail: Date of Birth (mm/dd/yyyy):

    US Phone #: Passport Expiration Date (mm/dd/yyyy):

    Residential Address (USA):


    House/Building # Street (Apt/Rm#)

    City State Zip Code


    Requested Service: Status at CMU:
    □ Travel Signature on my DS-2019 □ F-1 Student □ J-1 Researcher/Scholar
    □ Signature on my SSN Number Form □ J-1 Student □ H1-B Staff/Faculty
    □ Letter to help me obtain an SSN (J-1 Only) □ J-1 Student Intern
    □ Other:

    Signature: _____________________________________________________________ Date: _____________________________


    5000 Forbes Ave, Cyert Hall Suite 101, Pittsburgh, PA 15213
    Email: [email protected] ▪ Web: www.cmu.edu/oie ▪ Phone: (412) 268-5231

    Social Security Number Form: F-1 or J-1 Student On-Campus Employment


    Dear Social Security Administration officer:

    The following student is a lawful non-immigrant at Carnegie Mellon University. This student is eligible for
    employment; this information is supplied per federal regulation (20 CFR 422.105) and in support of the student’s
    social security number application.

    Carnegie Mellon Department Employer: to be completed by the hiring department/supervisor


    NOTE: The information requested below should be completed electronically. This form MUST have a handwritten signature.

    Student’s Name Surname/Family Name Given/First Name


    -As it appears on the
    student’s passport.
    Date of Birth (month/day/year)

    Carnegie Mellon on-campus employer or


    department name:

    Employer Address: 5000 Forbes Avenue, Pittsburgh, PA 15213


    Employer Identification Number: 25-0969449
    Position title:

    Employment start date:

    Number of units the student is enrolled in:

    Number of hours per week the student will be


    employed:
    NOTE: Enrollment in 36 units or more permits
    students to work up to 20 hours per week for all
    on-campus employment combined.
    Job duties (describe the work to be
    performed by the student):

    I certify that the student named above is working or has been offered the job described above:

    Hiring Dept./Supervisor (Handwritten Signature) Date Hiring Dept./Supervisor (Printed Name) Telephone

    For OIE use only:


    Basis for employment authorization – verified by an OIE Advisor (signature below)
    Authorization for the restricted employment can be found in the Code of Federal Regulations at 8 CFR 214.2(f) for F-1 students; J- 1 student
    authorization can be referenced at 22 CFR 62.23(g.) Students are allowed to work part-time (up to 20 hours per week) while school is in session
    and full-time during vacation periods (such as winter break or the vacation term.) For off-campus work, F-1 and J-1 students must apply for and
    receive work authorization.

    OIE Advisor (Handwritten Signature) Date OIE Designated School Officer PHI 214F 10187000
    OIE Alternative Responsible Officer P-1-00292
    Updated 8/2023

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