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B. CERTIFICATION BY DESIGNATED SCHOOL OFFICIAL DSO ALTERNATE/RESPONSIBLE OFFICER A/RO To Whom It May Concern This is to certify that is a F-1 or J-1 student attending Northeastern University Boston Massachusetts. The student has received on campus employment or a graduate assistantship as described in Section A of this form. Designated School Official Signature Original signature no stamps or facsimiles type or print Telephone contact for DSO or A/RO 617-373-2310 International Student Scholar Institute ISSI 405 Ell Hall www. issi. neu. edu 617-373-2310 phone 617-373-8788 fax ISSI 618 UC-SM-10109 Q W Date A. EVIDENCE OF ON-CAMPUS ENGAGEMENT/ EMPLOYMENT This is evidence of on-campus employment/engagement at Northeastern University for Name of the department where student will be working Nature of the student s activities e.g. cashier library aide residence proctor office assistant computer center technician Nature of student s activities if receiving stipend or tuition/fees waiver e.g. teaching assistant research assistant or residence assistant Start date Number of hours per week Not to exceed 20. The student has received on campus employment or a graduate assistantship as described in Section A of this form* Designated School Official Signature Original signature no stamps or facsimiles type or print Telephone contact for DSO or A/RO 617-373-2310 International Student Scholar Institute ISSI 405 Ell Hall www. issi. neu. edu 617-373-2310 phone 617-373-8788 fax ISSI 618 UC-SM-10109 Q W Date A. EVIDENCE OF ON-CAMPUS ENGAGEMENT/ EMPLOYMENT This is evidence of on-campus employment/engagement at Northeastern University for Name of the department where student will be working Nature of the student s activities e*g* cashier library aide residence proctor office assistant computer center technician Nature of student s activities if receiving stipend or tuition/fees waiver e*g* teaching assistant research assistant or residence assistant Start date Number of hours per week Not to exceed 20. Contact Information Contact phone number 617-373- Signature of immediate supervisor Student s immediate supervisor Employer Identification Number EIN 04 1679980. issi. neu. edu 617-373-2310 phone 617-373-8788 fax ISSI 618 UC-SM-10109 Q W Date A. EVIDENCE OF ON-CAMPUS ENGAGEMENT/ EMPLOYMENT This is evidence of on-campus employment/engagement at Northeastern University for Name of the department where student will be working Nature of the student s activities e*g* cashier library aide residence proctor office assistant computer center technician Nature of student s activities if receiving stipend or tuition/fees waiver e*g* teaching assistant research assistant or residence assistant Start date Number of hours per week Not to exceed 20. Contact Information Contact phone number 617-373- Signature of immediate supervisor Student s immediate supervisor Employer Identification Number EIN 04 1679980.

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