ETA 9141 Application for Prevailing Wage Determination

O MB Approval: 1205-0466

Expiration Date: XX/XX/XXXX

Application for Prevailing Wage Determination

ETA Form 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/.

A. Employment-Based Visa Information

1. Indicate the type of visa classification supported by this application (Write classification symbol): *

B. Requestor Point-of-Contact Information

1. Contact’s last (family) name *	2. First (given) name *		3. Middle name(s) *
4. Contact’s job title *
5. Address 1 *
6. Address 2
7. City *		8. State *	9. Postal code *
10. Country *		11. Province
12. Telephone number *	13. Extension	14. Fax Number
15. E-Mail Address

C. Employer Information

1. Legal business name *
2. Trade name/Doing Business As (DBA), if applicable §
3. Address 1 *
4. Address 2
5. City *	6. State *	7. Postal code *
8. Country *	9. Province
10. Telephone number *	11. Extension
12. Federal Employer Identification Number (FEIN from IRS) *	13. NAICS code (must be at least 4-digits) *

D. Job Offer Information

a. Job Description:

1. Job Title *
2. Suggested SOC (ONET/OES) code *	2a. Suggested SOC (ONET/OES) occupation title *

a. Job Description (continued)

3. Number of hours of work per week * Basic: _______ Overtime*: _______		3a. Hourly Work Schedule * A.M. (h:mm): ___ : ____ P.M. (h:mm): ___ : ____
4. Job Title of Supervisor for the Workers (if applicable) §
5. Does this position supervise the work of other employees? *  Yes  No			5a. If yes, number of employees worker § will supervise (if applicable) _______
6. Job duties – A description of the job duties to be performed MUST begin in this space. If necessary, add attachment to continue and complete description. *
7. Will travel be required in order to perform the job duties? *  Yes  No	7a. If “Yes”, please explain the travel requirements: §
8. Are there any other working conditions that affect the rate of pay? *  Yes  No	8a. If “Yes”, please specify the working conditions. §

b. Minimum Job Requirements:

1. Education: minimum U.S. diploma/degree required *  None  High School/GED  Associate’s  Bachelor’s  Master's  Doctorate (PhD)  Other degree (JD, MD, etc.)
1a. If “Other degree” in question 1, specify the diploma/ degree required §		1b. Indicate the major(s) and/or field(s) of study required § (May list more than one related major and more than one field)
2. Does the employer require a second U.S. diploma/degree? *			 Yes  No
2a. If “Yes” in question 2, indicate the second U.S. diploma/degree and the major(s) and/or field(s) of study required §
3. Is training for the job opportunity required? *			 Yes  No
3a. If “Yes” in question 3, specify the number of months of training required §	3b. Indicate the field(s)/name(s) of training required § (May list more than one related field and more than one type)
4. Is employment experience required? *			 Yes  No
4a. If “Yes” in question 4, specify the number of months of experience required §	4b. Indicate the occupation required §
5. Special Requirements - List specific skills, licenses/certificates/certifications, and requirements of the job opportunity. *

c. Place of Employment Information:

1. Worksite address 1 *
2. Address 2
3. City *	4. County *
5. State/District/Territory *	6. Postal code *
7. Will work be performed in multiple worksites within an area of intended employment or a location(s) other than the address listed above? *	 Yes  No
7a. If Yes in question 7, identify the geographic place(s) of employment with as much specificity as possible, such as the Metropolitan Statistical Areas (MSAs) or the city(ies)/township(s)/county(ies) and the corresponding state(s) where work will be performed. For job contractors filing under the H-2B program, submit a separate attachment identifying, by business name and mailing address, all physical locations where the services or labor will be performed. §

E. Prevailing Wage Determination

FOR OFFICIAL GOVERNMENT USE ONLY
PW tracking number				2. Date PW request received
3. SOC (ONET/OES) code	3a. SOC (ONET/OES) occupation title
4 $ __________ . ____ . Prevailing wage		4a. Wage level  I  II  III  IV  N/A
5. Per: (Choose only one)  Hour  Week  Bi-Weekly  Month  Year  Piece Rate
5a. If Piece Rate is indicated in question 2, specify the wage offer requirements :*
6. Prevailing wage source (Choose only one) SCA DBA OES CBA Other/Alternate Survey
6a. If “Other/Alternate Survey” in question 7, specify
7. Additional Notes Regarding Wage Determination
8. Determination date			9. Expiration date

F. OMB Paperwork Reduction Act (1205-0466)

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Persons are not required to respond to this collection of information unless it displays a currently valid OMB control number. Respondent’s reply to these reporting requirements is mandatory to obtain the benefits of temporary employment certification (Immigration and Nationality Act, Section 101). Public reporting burden for this collection of information is estimated to average 55 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate to the Office of Foreign Labor Certification * U.S. Department of Labor * Room C4312 * 200 Constitution Ave., NW * Washington, DC * 20210. Do NOT send the completed application to this address.

ETA Form 9141 FOR DEPARTMENT OF LABOR USE ONLY Page 4 of 4

PW Tracking Number:___________________ Case Status: __________________ Validity Period: ______________ to _______________