ETA-9141 Prevailing Wage Determination, PDF form, printed out fro

OMB Approval: 1205-0466
Expiration Date: 11/30/2011

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 *


4. Contact’s job title *
5. Address 1 *
6. Address 2
7. City *

3. Middle name(s) *









8. State *



10. Country *

11. Province

 




12. Telephone number *

13. Extension


15. E-Mail Address

9. Postal code *







14. Fax Number







 

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 *

 
ETA Form 9141

2a. Suggested SOC (ONET/OES) occupation title *


 


FOR DEPARTMENT OF LABOR USE ONLY

Page 1 of 4







PW Tracking Number:___________________
Case Status: 

__________________ Validity Period: ______________
to _______________

OMB Approval: 1205-0466
Expiration Date: 11/30/2011

Application for Prevailing Wage Determination
ETA Form 9141
U.S. Department of Labor
a. Job Description (continued)
3. Number of hours of work per week *



Basic: _______

3a. Hourly Work Schedule *








Overtime*: _______

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? *

7a. If “Yes”, please explain the travel requirements:

 



‰ Yes ‰ No
✔

8. Are there any other working
conditions that affect the rate of pay? *
‰ Yes

ETA Form 9141

8a. If “Yes”, please specify the working conditions.



‰
✔ No

FOR DEPARTMENT OF LABOR USE ONLY

Page 2 of 4







PW Tracking Number:___________________
Case Status: 

__________________ Validity Period: ______________
to _______________

OMB Approval: 1205-0466
Expiration Date: 11/30/2011

Application for Prevailing Wage Determination
ETA Form 9141
U.S. Department of Labor
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/
1b. Indicate the major(s) and/or field(s) of study required
(May list more than one related major and more than one field)
degree required





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


✔
‰ Yes

3. Is training for the job opportunity required? *
3a. If “Yes” in question 3, specify the number of
months of training required

(May list more than one related field and more than one type)


4. Is employment experience required? *
4a. If “Yes” in question 4, specify the number of
months of experience required

‰ No

3b. Indicate the field(s)/name(s) of training required




✔ Yes
‰

‰ No

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
‰ Yes
‰ No
✔
employment or a location(s) other than the address listed above? *
7a. If Yes in question 7, identify the geographic place(s) of employment with as much specificity as possible. If necessary,
submit an attachment to continue and complete a listing of all anticipated worksites.



ETA Form 9141

FOR DEPARTMENT OF LABOR USE ONLY

Page 3 of 4







PW Tracking Number:___________________
Case Status: 

__________________ Validity Period: ______________
to _______________

OMB Approval: 1205-0466
Expiration Date: 11/30/2011

Application for Prevailing Wage Determination
ETA Form 9141
U.S. Department of Labor
E. Prevailing Wage Determination
FOR OFFICIAL GOVERNMENT USE ONLY
1. PW tracking number

2. Date PW request received

3. SOC (ONET/OES) code

4. Prevailing wage

3a. SOC (ONET/OES) occupation title

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)
‰

OES

‰

CBA

‰

DBA

‰

SCA

‰

Other/Alternate Survey

6a. If “Other/Alternate Survey” in question 6, specify

7. Additional Notes Regarding Wage Determination

8. Determination date

9. Expiration date

F. OMB Paperwork Reduction Act (1205-0466)
k

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 _______________