CPT ASSIGNMENT ACCEPTANCE FORM - INDUSTRIAL PRACTICE PROGRAMS

DATE: ______________________

ASSIGNMENT SEMESTER(S): _____________________

CONTINUING: YES____ NO____

NAME: ____________________________________________________________ UTD STUDENT ID: _________________________________

DEGREE: __________

MAJOR: __________

*ARE YOU GRADUATING THIS SEMESTER:

YES_____

NO______

HOW MANY CREDIT HOURS DO YOU HAVE REMAINING TO COMPLETE YOUR DEGREE? _____________________________
TYPE OF POSITION: FULL-TIME: ____ PART-TIME:____ HOURS/WEEK: _________ SALARY/HOUR: _______________
POSITION TITLE: ________________________________________________________ START DATE: _________ END DATE: __________
POSITION DESCRIPTION: _________________________________________________________________________________________________
__________________________________________________________________________________________________________________________
COMPANY: _______________________________________________DEPARTMENT:_________________________________________________
SUPERVISORS
SUPERVISORS
SUPERVISORS
NAME: ________________________________________PHONE NUMBER: ____________________ E-MAIL: ___________________________
PHYSICAL
ADDRESS: ______________________________________________________CITY:________________________STATE:______ZIP:___________
*Authorization for CPT employment under the Jonsson School Industrial Practice Programs must be in
conjunction with enrollment in one of the Jonsson School ECSC co-op courses, based on major/degree:
5177, 5179, 3177, 3179, 4378
Will you be taking other UTD courses while working?

Yes: _____

*How many hours? ________

ECSC

No: _______

*Please read and initial the following:

_______ I understand that with my enrollment in the ECSC course, it is my responsibility to follow the
add/drop/withdrawal deadlines described by the academic calendar prepared by the Registrars Office. Any
refund to tuition and fees is based on the published refund policies of the Bursars Office. If my internship
is cancelled or shortened after the add/drop deadlines, I understand that there is no possibility of
recovering the tuition and fees from any university office or staff member.
_____ I understand I will receive one credit hour for successfully completing the course. I understand my grade in the course will, in part, be
determined by a Performance Evaluation completed by my work supervisor and by completion of the IPP Work Report. I understand that if I
withdraw from or do not successfully complete the ECSC Co-op Course I am not authorized to work and that I may be in violation of my F-1
status.
______ I have met the eligibility requirements of the Jonsson School IP Programs and the U.S. CIS regulations for CPT. If I am on academic
probation and/or the UTD Office of International Student Services cannot authorize my I-20 for CPT employment, I give permission to the staff
of the Jonsson School Industrial Practice Programs or the staff of the Office of International Student Services to notify the employer regarding
my inability to report for the CPT assignment. I understand that the Special Use Fee, $100 CPT, will be assessed through the UTD Bursar
Office after the semester begins.
______ I understand that once I am approved and processed for this IPP assignment for this semester, I will not be processed for another
employer in this same semester. I understand that upon acceptance of the offer, I agree to complete the assignment and will not terminate
without receiving approval from the IPP Department.
______ I understand that in order to be approved for Curricular Practical Training, the work experience must be in a field related to my
academic program. I believe that this position will give me productive work experience in the area of my degree and major.
______ I understand that I may NOT work as an independent contractor; I must be on the employers payroll and appropriate Federal/State
income taxes must be withheld from my paycheck.
______ I understand that I may not work on campus while doing off-campus Curricular Practical Training.

Student Signature: ________________________________________ Date: _____________________

Please Read the Following Statements Before Filling Out Our Form
With few exceptions you are entitled, on your request, to be informed about the information U.T. Dallas collects about you. Under Sections 552.021 and 552.023 of the Texas Government Code, you are entitled to receive and
review the information. Under Section 559.004 of the Texas Government Code, you are entitled to have U.T. Dallas correct information about you that is held by us and that is incorrect. Be assured that your UTD records are
protected from unauthorized disclosure by federal law.
Your Social security number (SSN) or UTD Identification number is being requested because it is a unique identification number which is maintained for the purpose of assurance that the correct student record is being updated, for
tracking purposes and for state and federal report requirements. The disclosure of such information is voluntary. Your disclosure of your social security number or UTD identification number will be governed by the Public
Information Act (Chapter 552 of the Texas Government Code).
November 2007