ETA Form 9141 Application for Prevailing Wage Determination

OMB Approval: 1205-0466
Expiration Date: 04/30/2012

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 *

10. Country *

11. Province

12. Telephone number *

13. Extension

9. Postal code *

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 *

8. Country *

9. Province

10. Telephone number *

11. Extension

12. Federal Employer Identification Number

(FEIN from IRS) *

13. NAICS code

7. Postal 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
PW Tracking Number:

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

FOR DEPARTMENT OF LABOR USE ONLY
Case Status:

Validity Period:

Page 1 of 4
to

OMB Approval: 1205-0466
Expiration Date: 04/30/2012

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*:

A.M. (h:mm):

4. Job Title of Supervisor for the Workers (if applicable)

:

P.M.

(h:mm):

:

§

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 .UST 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

ETA Form 9141
PW Tracking Number:

§

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

§

No

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

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

No

FOR DEPARTMENT OF LABOR USE ONLY
Case Status:

Validity Period:

Page 2 of 4
to

§

OMB Approval: 1205-0466
Expiration Date: 04/30/2012

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
2a. If “Yes” in question 2, indicate the second U.S. diploma/degree and the major(s) and/or field(s) of study required

No

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

No

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

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

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

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
PW Tracking Number:

FOR DEPARTMENT OF LABOR USE ONLY
Case Status:

Validity Period:

Page 3 of 4
to

OMB Approval: 1205-0466
Expiration Date: 04/30/2012

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

5. Per: (Choose only one)

Hour
Week
Bi-Weekly
Month
5a. If Piece Rate is indicated in question 2, specify the wage offer requirements :*
6. Prevailing wage source

II
Year

III

IV

N/A

Piece Rate

(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

k

9. Expiration date

F. OMB Paperwork Reduction Act (1205-0466)
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
PW Tracking Number:

FOR DEPARTMENT OF LABOR USE ONLY
Case Status:

Validity Period:

Page 4 of 4
to