GREEN CARD REQUEST FORM EMPLOYEE INFORMATION Employee Last Name First Name Middle Initial Department Name College Position Date of hire Date of offer from Department Employee Phone Number st Date of issuance of 1 H1B or Years of eligibility left on H1B or Expiration date of current H1B or other status currently on other status currently on other status currently on Direct Supervisor’s Name Title Phone Number APPROVAL By signing below, I authorize the Human Resource and Legal and Office of Legal Affairs to beginning By signing below, I authorize the Human Resource Department Departments to proceed with proceed the application for a green card green above the above mentioned I understand that this includes with beginning the application for for the card formentioned employee. employee. I understand that this includes providing an index for these fees, which have been estimated to be $5000 - $8000, in addition providing an account number for these fees, which have been estimated to be $4500 - $5000, in the $475 the fee charges, which are approximately $600. toaddition tofilingfilingfor the I140 Immigrant Petiton. Dean / AVP Signature Dean / AVP Name Printed Date 71108 Index for fees to be charged to Account Number for fees to be charged to Account Object Code Please forward the signed to Michael Dills. Please forward the signed formform to MattAllen, either via e-mail (email@example.com) with an electronic signature firstname.lastname@example.org and from the e-mail account either of the Dean/AVP or through inter-campus mail at MS 205.