Form ETA 9141C ETA 9141C Application for Prevailing Wage Determination

OMB Approval: 1205-053X
Expiration Date: XX/XX/XXXX

Application for Prevailing Wage Determination
Form ETA-9141C
U.S. Department of Labor
IMPORTANT: Employers and authorized preparers must read the general instructions carefully before completing the Form ETA-9141C. A copy of the instructions
can be found at http://www.foreignlaborcert.doleta.gov/. If you are not submitting this electronically, please complete ALL required fields/items containing an asterisk
(*) and any fields/items where a response is conditional as indicated by the section (§) symbol.

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 (apartment/suite/floor and number) §
7. City *

8. State *

10. Country *

11. Province §

12. Telephone Number *

13. Extension §

9. Postal Code *

14. Business Email Address *

C. Employer Information
1. Legal Business Name *
2. Trade Name/Doing Business As (DBA), if applicable §
3. Address 1 *
4. Address 2 (apartment/suite/floor and number) §
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 *

D. Job Opportunity Information
a. Job Description
1. Job Title *
2.

SOC Occupational Code (suggested)

Form ETA-9141C
PW Tracking Number: __________________

2a. SOC Occupation Title (suggested)

FOR DEPARTMENT OF LABOR USE ONLY
Case Status: __________________

Determination Date: _____________

Page 1 of 4
Validity Period: _____________ to _____________

OMB Approval: 1205-053X
Expiration Date: XX/XX/XXXX

Application for Prevailing Wage Determination
Form ETA-9141C
U.S. Department of Labor
a. Job Description (continued)
3. Job Title of Supervisor for this Position §
4. Does this position supervise the work of
other employees? *

❑ Yes
❑ No

4a. If “Yes” to question 4, enter the number of
employees worker will supervise. §

4b. If “Yes” to question 4, indicate the level of the employees to be supervised: §

❑ Subordinate

❑ Peer

5. Job duties – Please provide a description of the duties to be performed with as much specificity as possible, including
details regarding the areas/fields and/or products/industries involved. A description of the job duties to be performed MUST
begin in this space. *

6. Will travel be required in order to
perform the job duties? *

❑ Yes

6a. If “Yes” to question 6, please provide details of the travel required, such as area(s),
frequency and nature of the travel. §

❑ No

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. §

Form ETA-9141C
PW Tracking Number: __________________

FOR DEPARTMENT OF LABOR USE ONLY
Case Status: __________________

Determination Date: _____________

Page 2 of 4
Validity Period: _____________ to _____________

OMB Approval: 1205-053X
Expiration Date: XX/XX/XXXX

Application for Prevailing Wage Determination
Form ETA-9141C
U.S. Department of Labor
b. Minimum Job Requirements (continued)
3.

Is training for the job opportunity required? *

3a. If “Yes” in question 3, specify the number of months
of training 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

4. Is employment experience required? *
4a. If “Yes” in question 4, specify the number of months
of experience required. §
5.

❑ No

❑ No

4b. Indicate the occupation(s) required. §

Special Requirements - List specific skills, licenses/certificates/certifications, and requirements of the job opportunity. *

c. Place of Employment Information
1.

Worksite Address *

2.

Worksite Address § (apartment/suite/floor and number)

3.

City *

4. State *

5. Postal Code *

6.

Will work be performed in multiple worksites within an area of intended employment or a
❑ Yes ❑ No
location(s) other than the address listed above? *
6a. If “Yes” in question 6, identify the geographic place(s) of employment indicating each metropolitan statistical area (MSA)
or the independent city(ies)/township(s)/county(ies) (borough(s)/parish(es)) and the corresponding state(s) where work
will be performed. If necessary, submit a second completed Form ETA-9141C with a listing of the additional anticipated
worksites. Please note that wages cannot be provided for unspecified/unanticipated locations. §

Form ETA-9141C
PW Tracking Number: __________________

FOR DEPARTMENT OF LABOR USE ONLY
Case Status: __________________

Determination Date: _____________

Page 3 of 4
Validity Period: _____________ to _____________

OMB Approval: 1205-053X
Expiration Date: XX/XX/XXXX

Application for Prevailing Wage Determination
Form ETA-9141C
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

3a. SOC (ONET/OES) occupation title

4. Prevailing wage

4a. OES Wage level

❑

$ __________ . ____

I

❑

II

❑

III

❑

IV

❑

N/A

5. Per: (Choose only one)

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

❑

Year

❑

Piece Rate

❑

SCA

❑

Other/Alternate
Survey

6. Prevailing wage source (Choose only one)

❑

OES
(All Industries)

❑

❑

OES

CBA

❑

DBA

(ACWIA – Higher Education)

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

7. Additional Notes Regarding Wage Determination

8. Determination date

9. Expiration date

Public Burden Statement (1205-053X)
Persons are not required to respond to this collection of information unless it displays a currently valid OMB control number. Public reporting
burden for this collection of information is estimated to average 46 minutes to complete the form, including the time for reviewing instructions,
searching existing data sources, gathering and maintaining the needed data, and completing and reviewing the collection of information. The
obligation to respond to this data collection is required to obtain/retain benefits (Northern Mariana Islands U.S. Workforce Act of 2018, 48 U.S.C.
1806 et seq.). Please send comments regarding this burden estimate or any other aspect of this information collection to the U.S. Department of
Labor * Employment and Training Administration * Office of Foreign Labor Certification * 200 Constitution Ave., NW * Box PPII 12-200 *
Washington, DC * 20210 or by email to [email protected]. Please do not send the completed application to this address.
Form ETA-9141C
PW Tracking Number: __________________

FOR DEPARTMENT OF LABOR USE ONLY
Case Status: __________________

Determination Date: _____________

Page 4 of 4
Validity Period: _____________ to _____________