Form ETA 9141 ETA 9141 Job Offer and Required Wage Determination Request

O MB Approval:

Expiration Date

Job Offer and Required Wage Request Form

Form ETA 9141

U.S. Department of Labor

Please read and review the instructions carefully before completing this form and print legibly. A copy of the instructions can be found at http://www.foreignlaborcert.doleta.gov/. Except for items marked with an asterisk (*) , which may be left blank because they either do not apply or are conditioned based on a response to another item, all other data collection items contained on this form must be completed.

Purpose of this form: In accordance with Federal regulations, employers shall obtain a prevailing wage or required offered wage rate determination from the appropriate ETA application processing center, one located each in Atlanta and Chicago, serving the area of intended employment prior to filing an application for permanent or temporary labor certification. The job offer information contained on this form will be used by the ETA application processing center to issue a required wage determination, which will subsequently be used by the employer to conduct pre-filing recruitment of U.S. workers for the job opportunity.

OMB Paperwork Reduction Act Statement: These reporting instructions have been approved under the Paperwork Reduction Act of 1995. Persons are not required to respond to this collection of information unless it displays a currently valid OMB control number. Obligations to reply are mandatory (Immigration and Nationality Act, Sections 203(b)(3), 212(a)(5), and 218). Public reporting burden for this collection of information is estimated to average 50 minutes per response, including the time to review instructions, search existing data sources, gather and maintain the data needed, and complete and review the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to the U.S. Department of Labor, Room C-4312, 200 Constitution Ave. NW, Washington, DC 20210. (Paperwork Reduction Project OMB 1205-0NEW.)

A. Employment-Based Visa Classification Information

1. Indicate the type of visa classification (Choose only one box below) Permanent Employment Temporary Employment  PERM Program  H-1B Program  H-2B Program  H-2A Program
2. Number of openings to be filled by job offer	Anticipated Period of Employment
	3a. From (mm/dd/yyyy)	3b. To (mm/dd/yyyy)

B. Requestor Point-of-Contact Information

1a. Contact’s Last (Family) Name 1b. First (Given) Name 1c. Middle Name(s)
2. Firm/Business Name
3a. Address 1
3b. Address 2*
4. City	5. State/Province	6. Country	7. Postal Code
8a. Phone Number		8b. Fax Number
9. E-Mail Address*

C. Employer or Association Information

1. Employer’s name (Headquarters or Main Office)
2. Trade Name/Doing Business As (DBA), if applicable*
3a. Address 1
3b. Address 2*
4. City	5. State/Province		6. Country	7. Postal Code
8a. Phone number (area code and seven digit number) ( ) -			8b. Extension*
9. Number of employees currently on the employer’s payroll in area of intended employment		10. Year commenced business (or date EIN issued for households)
11. Employer Identification Number (EIN from IRS)		12. NAICS/Industry code (must be at least 4-digits)

D. Job Offer Information

a. Description:

1. Job title
2. Number of hours of work per week Basic: Overtime*:	2a. Hourly Work Schedule A.M. (h:mm): P.M. (h:mm):
3. Job Title of Supervisor (if applicable)*	4. Number of employees worker will supervise (if applicable)*
5. Job duties – A description of the job duties to be performed MUST begin in this space. If submitting Form ETA 9141 by mail, add attachment if necessary to continue and complete description.

D. Job Offer Information (continued)

6. Special Requirements - List other specific skills, licenses/certificates/certifications, and other special requirements of the job opportunity. Description MUST begin in this space. If submitting Form ETA 9141 by mail, add attachment if necessary to complete special requirements. Write "None" in the space below if the job opportunity does not contain any special requirements.
7. Will any On-the-Job Training (OJT) be provided to workers in order to perform the job duties?  Yes  No	7a. If Yes, number of weeks of OJT to be provided:

b. Minimum Job Requirements:

1. Education: minimum U.S. level required:  None  High School  Associate’s  Bachelor’s  Master's  Doctorate  Other
1a. If Other in question 1, specify the education required:
1b. Indicate the major field(s) of study (May list more than one related major and more than one field)
2. Is training for the job opportunity required?  Yes  No	2a. If Yes, number of months of training required:
2b. If Yes in question 2, indicate the field(s)/type(s) of training:
3. Is employment experience required?  Yes  No	3a. If Yes, number of months of experience required:
3b. If Yes in question 3, indicate the occupation(s) required

c. Primary Worksite Information:

Important Note: The worksite address must be a physical location and cannot be a P.O. Box. If work will be

performed in multiple locations, then complete this section as follows:

• Answer “Yes” to Question 1;

• Indicate whether the work to be performed in multiple locations is based on an itinerary;

• Record the worksite location where the work is currently being performed or is expected to begin; and

• Under section “d. Additional Worksite Information,” provide as much geographic detail as possible (e.g., city/state, township/state, county/state) to cover all locations where work will be performed .

1. Does the job opportunity involve multiple work locations?	 Yes  No
2. If “yes,” indicate whether the work to be performed is based on an itinerary?	 Yes  No  NA

3. Employer’s name
4. Trade Name/Doing Business As (DBA), if applicable*
5a. Worksite Address 1
5b. Worksite Address 2*
6. City/Township	7. State	8. County	9. Postal Code
Section d. must be completed for job opportunities involving an itinerary or where special procedures granted by the Department apply
10. If applicable, total number of workers performing services or labor at this worksite location*		Anticipated Period of Employment
		11a. From (mm/dd/yyyy)*	11b. From (mm/dd/yyyy)*

d. Additional Worksite Information:

List all other locations where work will be performed under the job opportunity. Provide as much geographic detail as possible using the fields in this section. If submitting Form ETA 9141 by mail, add attachment if necessary to complete the worksite information.

1. City/Township	2. State	3. County
4. If applicable, total number of workers performing services or labor at this worksite location*		Anticipated Period of Employment*
		5a. From (mm/dd/yyyy)*	5b. From (mm/dd/yyyy)*
6. City/Township	7. State	8. County
9. If applicable, total number of workers performing services or labor at this worksite location*		Anticipated Period of Employment*
		10a. From (mm/dd/yyyy)*	10b. From (mm/dd/yyyy)*
11. City/Township	12. State	13. County
14. If applicable, total number of workers performing services or labor at this worksite location*		Anticipated Period of Employment*
		15a. From (mm/dd/yyyy)*	15b. From (mm/dd/yyyy)*

e. Additional Terms and Conditions of Employment (For H-2A Applications ONLY)

Important Note: Appendix A contains a full description of the employer’s job opportunity, including the duties to be performed, minimum job requirements, worksite location(s), duration of employment, benefits, wages, and other terms and conditions. Applications that fail to attach Appendix A will be considered incomplete and not accepted for determining the required wage rate or conducting recruitment of U.S. workers.

Please confirm that Appendix A will be submitted simultaneously with this application.

 Yes  No  NA

E. Employer Declaration

I declare under penalty of perjury that I have read and reviewed this application and that to the best of my knowledge the information contained therein is true and accurate. I understand that to knowingly furnish false information in the preparation of this form and any supplement thereto or to aid, abet, or counsel another to do so is a felony punishable by a $250,000 fine or 5 years in the Federal penitentiary or both (18 U.S.C. 1001). The information contained in this application related to the job opportunity describes the actual terms and conditions of the employment being offered by me and contains all the material terms and conditions of the job.

1a. Last (Family) name 1b. First (Given) name 1c. Middle initial
2. Title
3. Signature	4. Date signed (mm/dd/yyyy)

F. Prevailing Wage Determination (Required Offered Wage Rate for H-2A)

FOR GOVERNMENT USE ONLY
1. PW tracking number		2. Date PW request received (mm/dd/yyyy)
3. SOC (ONET/OES) code		4. SOC (ONET/OES) occupation title
5a. Wage level  I  II  III  IV		5b. Geographic area level
6 $ _____ . ____ a. Prevailing wage | 6b. For H-2A only |Required Wage Rate | $ _______.____ |	6c. Per: (Choose only one)  Hour  Week  Bi-Weekly  Month  Year  Piece Rate
6d. Prevailing wage source  OES  CBA  DBA  SCA  Employer provided  Other
6e. If Other is indicated in question 6, specify:*
7. Determination date (mm/dd/yyyy)			8. Expiration date (mm/dd/yyyy)

APPENDIX A

ADDITIONAL TERMS AND CONDITIONS OF EMPLOYMENT

Job Offers Filed for Temporary Labor Certification under the H-2A Program ONLY

1. Location and Description of Housing Arrangements

2. Transportation Arrangements

3. Board Arrangements (check applicable statements)

• Employer will provide 3 meals per day and will deduct $ _________ per day.

• Employer will furnish free and convenient cooking and kitchen facilities so that workers may prepare their own meals.

• Employer will provide (on a voluntary basis) transportation to assure workers access to stores where they can purchase groceries, if the employer is providing cooking and kitchen facilities.

4. Wage Rates, Special Pay, and Deduction Information

Crop Activity	Hourly Wage	Piece Rate Wage	Piece Rate Unit(s)	Special Pay (bonus, etc.)	Deductions from Pay
	$ ____ . ___	$ ____ . ___			Social Security	 Yes  No
	$ ____ . ___	$ ____ . ___			Federal Tax	 Yes  No
	$ ____ . ___	$ ____ . ___			State Tax	 Yes  No
	$ ____ . ___	$ ____ . ___			Meals	 Yes  No
	$ ____ . ___	$ ____ . ___			Health Insurance	 Yes  No
	$ ____ . ___	$ ____ . ___			Other (specify)	 Yes  No
Record the pay period for the workers (e.g., weekly, bi-weekly, monthly) and any other details about the pay
Does the employer pay Unemployment insurance taxes?					 Yes  No
Does the employer possess valid workers’ compensation insurance policy?					 Yes  No
Are tools provided at no charge to the workers?					 Yes  No

5. Other Special Instructions

Explanation as to how U.S. workers should be referred for consideration/hire

Will employer accept collect calls from qualified eligible individuals referred to the job?	 Yes  No
Will the nearest local office of the SWA accept collect calls from qualified eligible individuals referred to the job?	 Yes  No

ETA 9141 Validity period: __________________ to _____________________ Page 7 of 7

Tracking Number: ___________________ Status: ___________________