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(Please print or type): 1. Name: (Family in CAPS) (First) (Middle) 2. Date of birth: 3. Student admission number: 4. Date first granted F-1 or M-1 status: 5. Level of education being sought: 6. Student's major field of study: 7. Describe the proposed employment for practical training: Beginning date: Ending date: Number of hours per week: 8. List all periods of previously authorized employment for practical training: A. Curricular or work/study: B. Post completion of studies Sign.

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