H-1B Visa Extension Request Form

H-1B Visa Extension Request Form

Personal Information

Date of Birth:    Country of Citizenship:    Passport Number:

Email:    Primary Phone:

Current Immigration Status

Current Nonimmigrant Status:    I-94 Admission Number:

Passport Country of Issue:    Current H-1B Expiration Date:

Employer and Petition Details

HR Contact Name:    HR Contact Phone:

Current Petition Receipt Number (if available):    Prior Approval Notice (I-797) Number:

LCA Certified Date:    Prevailing Wage / Offered Wage: $

Position Information

Department:    Reporting Manager:

Employment Type: Full-time    Part-time

Requested Start Date:    Requested End Date:

Immigration History

Ever been denied an immigration benefit or had a petition refused/withdrawn? Yes    No

Employment History (Most Recent)

Title:    Dates Employed: to

Title:    Dates Employed: to

Education

Credential Evaluation Attached: Yes    No

Professional References

Supporting Documents Checklist

Passport biographic page copy    I-94 copy    Prior I-797(s)

Most recent paystubs (3 months)    Certified LCA    Employer support letter

Resume    Diploma / transcripts    Other (describe below)

Administrative Options

Request Premium Processing: Yes    No

Is this an amended petition (change in duties, worksite, or salary)? Yes    No

Legal Disclosures and Company Policies

At-Will Employment: Submission of this extension request does not alter the at-will nature of employment where applicable. Nothing in this request constitutes a promise of continued employment for any fixed duration unless set forth in a separate written agreement signed by an authorized company representative.

Equal Opportunity Employer: The employer does not discriminate on the basis of race, color, religion, sex, national origin, disability, age or other protected characteristics in any employment decision. This form is used solely for immigration and employment authorization purposes.

Applicant Certification and Authorization

I certify, under penalty of perjury, that the information provided on this form and in any accompanying documentation is true, correct, and complete to the best of my knowledge. I understand that false statements or material omissions may result in denial of the requested immigration benefit and may subject me to penalties under applicable law.

I authorize the employer and its authorized representatives to prepare and file an H-1B extension petition on my behalf, to provide the Department of Labor and immigration authorities with information necessary to support the petition, and to obtain and release employment, immigration, and educational records as necessary to pursue the petition.

I further authorize the employer to conduct background checks and to verify the information provided herein. I understand that additional documentation may be requested and that I must cooperate in providing accurate, timely information.

Applicant acknowledges that any filing decisions (including fee payment options and premium processing elections) are made by the employer and its legal representatives in compliance with applicable law and that the employer will notify the applicant of the filing and receipt number when available.

Consent to Electronic Communication: By submitting this form, I consent to receive notices, requests for further information, and electronic communications related to this petition at the email address provided above.

I understand and agree to the certifications above: I certify

Employer Attestation (For Administrative Use)

Employer hereby attests that the information provided in support of this H-1B extension petition is accurate, that the position qualifies as specialty occupation under applicable law, that the employer will pay the required wage to the beneficiary, and that the employer has complied with all required Labor Condition Application obligations. This attestation is made by an authorized company representative.

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