Form I-129S Nonimmigrant Petition Based on Blanket L Petition

OMB No. 1615-0010; Expires 01/31/2012

Form I-129S, Nonimmigrant Petition
Based on Blanket L Petition

Department of Homeland Security
U.S. Citizenship and Immigration Services

START HERE - Please type or print in black ink.

Part 1.

For USCIS Use Only

Information About Employer

Receipt

Returned

Sponsoring Company of Organization's Name

Date
Date
Resubmitted

Address - ATTN:

Date

Room/Suite #

Street Number and Name

Date
Reloc Sent

City or Town

Country

State or Province

Zip/Postal Code

Date
Date
Reloc Sent
Date

Part 1A. Data Collection

Date

Does the petitioner employ 50 or more individuals in the U.S. ?

Yes

No

If yes, are more than 50% of those employees in H-1B or L
nonimmigrant status?

Yes

No

Petitioner
Interviewed
on
Beneficiary
Interviewed

Part 2.

Information About Employment

on
Approved as:

This alien will be a:

Manager/executive

a. Manager/Executive

Specialized knowledge

b. Specialized knowledge professional

on

Blanket petition approval number:

Validity Dates:
From:
To:

Part 3. Information About Employee
Family Name

Denied (Give reason)

Given Name

Middle Name

Foreign Address: Street Number and Name

City or Town

Country

Room/Suite #

Action Block

State or Province

Zip/Postal Code

Date of Birth (mm/dd/yyyy)

To Be Completed by
Attorney or Representative, if any.

Country of Birth

Country of Citizenship/Nationality

Fill in box if G-28 is attached to represent the
petition.
ATTY State License #

Form I-129S (Rev. 11/23/10)N

Part 4. Additional Information About the Employment
Room/Suite #

Address: Street Number and Name

State or Province

City or Town

Country

Zip/Postal Code

Date of intended employment and Wage
From (mm/dd/yyyy)

To (mm/dd/yyyy)

Weekly Wage

Hours Per Week

Title and detailed description of duties to be performed.

Give the alien's dates of prior periods of stay in the United States in a work authorized capacity and the type of visa.

Give the alien's dates of employment and job duties for the immediate prior 3 years.

Summarize the alien's education and other work experience.

Form I-129S (Rev. 11/23/10)N Page 2

Part 5. Signature Read the information on penalties in the instructions before completing this section.
I certify, under penalty of perjury under the laws of the United States of America, that this petition and the evidence submitted with it
are all true and correct. I am filing this on behalf of an organization, and I certify that I am empowered to do so by that organization. If
this petition is to extend a prior petition, I certify that the proposed employment is under the same terms and conditions as in the prior
approved petition. I authorize the release of any information from my records, or from the petitioning organizations records that U.S.
Citizenship and Immigration Services needs to determine eligibility for the benefit being sought.
Signature

Date (mm/dd/yyyy)

Print or Type Your Name

Daytime Telephone Number (with area code)

E-Mail Address (If any)

NOTE: If you do not completely fill out this form or fail to submit required documents listed in the instructions, the person(s)
petitioned may not be found eligible for the requested benefit and this petition may be denied.

Part 6. Signature of Person Preparing Form, If Other Than Above (Sign below)
Signature of Preparer

Date (mm/dd/yyyy)

Print or Type Your Name

Daytime Telephone Number (with area code)

E-Mail Address (If any)

Firm Name and Address

Form I-129S (Rev. 11/23/10)N Page 3