Form ETA-9165 Employer-Provided Survey Attestations to Accompany H-2B

OMB Approval: 1205-0516

E xpiration Date: 10/31/2015

Employer-Provided Survey Attestations to Accompany

H-2B Prevailing Wage Determination Request Based on a Non-OES Survey

Form ETA-9165

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/. Those items marked with * are required. Items marked with § are required if the condition listed is met.

A. Requestor Point-of-Contact Information (from Form ETA-9141, Section B)

1. Contact’s last (family) name *	2. First (given) name *		3. Middle name(s) *
4. Telephone number *	5. Extension	6. Fax Number
7. E-Mail Address

B. Employer Information (from Form ETA-9141, Section C)

1. Legal business name *
2. Trade name/Doing Business As (DBA), if applicable
3. Telephone number *	4. Extension
5. Federal Employer Identification Number (FEIN from IRS) *	6. NAICS code (must be at least 4-digits) *

C. Employer-Provided Survey Information

1. Survey name or title *
2. Is a collective bargaining agreement applicable to the job opportunity? *			 Yes  No
3. Are professional sports league’s rules or regulations applicable to the job opportunity? *			 Yes  No
4.	No data for the survey was collected by any H-2B employer or any H-2B employer’s agent, representative, or attorney.			 Yes  No
5.	Name of third party surveyor. _____________________________________________________________________________________________
6.	Name of the official representative of the third party surveyor who approved the survey.
	Contact’s last (family) name ____________________________________________	First (given) name ________________________________
7. The survey is based on wages paid 24 months or less before the date on which the survey was submitted to ETA. *					 Yes  No
8. This is the most recent edition of the survey. (Answer “yes” if this is the only edition of the survey.) *					 Yes  No

4. Relationship to job opportunity listed on the Form ETA-9141

1. Title of job(s) included in the survey *
2. Duties of the job(s) included in the survey (submit an attachment if more space is required): *
3. Identify the area of intended employment (see definition in instructions) covered by the survey. *
4. The survey was expanded to include workers beyond the area of intended employment *		 Yes  No
4a. If yes to question 4, the geographic area surveyed was §
4b. If yes to question 4, the survey was expanded beyond the area of intended employment (check all that apply) §
	to meet the 30 worker minimum.
	to meet the 3 employer minimum.
	The area surveyed was expanded for another reason. Provide below (attach additional sheet if necessary):

5. Survey Methodology

1. It was determined that ___________ employers employ workers in the occupation and geographic area surveyed. *
2. The following sources were used to determine the number of employers employing workers in the occupation and geographic area surveyed: *
3. Did the surveyor attempt to contact all employers employing workers in the occupations in the geographic area surveyed or a sample of employers in the geographic area? *	 All Employers  Sample
3a. If a sample, was the sample selected randomly? §	 Yes  No
3b. If a sample, provide a brief summary of the procedures used to randomize the sample: §
4. The surveyor attempted to solicit responses from ___________ employers in conducting the survey. *
5. For each responding employer, the survey includes the wages of all workers in the occupation regardless of skill level or experience, education, and length of employment. *	 Yes  No
6. The survey includes data collected across industries that employ workers in the occupation. *	 Yes  No
7. The survey reflects the mean wage for all workers it covers. *	 Yes  No
7a. The mean wage is $ _____ . ____ per __________________ (specify whether hourly, weekly, or monthly). §
8. The survey reflects the median wage for all workers it covers. *	 Yes  No
8a. The median wage is $ _____ . ____ per __________________ (specify whether hourly, weekly, or monthly). §
9. The hourly, weekly, or monthly wage reported from the survey is based on data from _______ employers (minimum of 3), and reflects wages from _______ workers (minimum of 30) within the occupation in the geographic area surveyed. *
10. The hourly, weekly, or monthly wage rate reported by the survey includes all types of wages paid to workers, including base rate of pay, commissions, cost-of-living allowance, deadheading pay, guaranteed pay, hazard pay, incentive pay, longevity pay, piece rate, portal-to-portal rate, production bonus, and tips. *	 Yes  No
11. The survey includes wages from workers in the occupation regardless of immigration status. *	 Yes  No

6. 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).

1. Last (family) name *	2. First (given) name *		3. Middle name(s) *
4. Title *
6. Signature *		6. Date Signed *

6. OMB Paperwork Reduction Act (1205-0516)

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 required 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 25 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 ● Box 12-200 ● 200 Constitution Ave., NW, ● Washington, DC 20210. Do NOT send the completed application to this address.

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