O MB Approval: 1205-0508
Expiration Date: XX/XX/XXXX
Application for Prevailing Wage Determination
Form ETA-9141 – Appendix A, Request for Additional Worksite(s)
U.S. Department of Labor
Important Note: Identify any additional worksite(s) for which the employer is requesting issuance of an additional prevailing wage.
Additional Worksite 1
County/State or BLS Area (Metropolitan or Non-Metropolitan Statistical Areas) Name *
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For Official Government Use Only |
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SOC Code: SOC Title: |
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Minimum Requirements Prevailing Wage Source:
Prevailing Wage per Minimum Requirements: $________ per ____ |
Alternative Requirements (PERM and H-1B only) Prevailing Wage Source:
Prevailing Wage per Alternative Requirements: $________ per ____ |
Additional Worksite 2
County/State or BLS Area (Metropolitan or Non-Metropolitan Statistical Areas) Name *
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For Official Government Use Only |
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SOC Code: SOC Title: |
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Minimum Requirements Prevailing Wage Source:
Prevailing Wage per Minimum Requirements: $________ per ____ |
Alternative Requirements (PERM and H-1B only) Prevailing Wage Source:
Prevailing Wage per Alternative Requirements: $________ per ____ |
Additional Worksite 3
County/State or BLS Area (Metropolitan or Non-Metropolitan Statistical Areas) Name *
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For Official Government Use Only |
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SOC Code: SOC Title: |
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Minimum Requirements Prevailing Wage Source:
Prevailing Wage per Minimum Requirements: $________ per ____ |
Alternative Requirements (PERM and H-1B only) Prevailing Wage Source:
Prevailing Wage per Alternative Requirements: $________ per ____ |
FOR DEPARTMENT OF LABOR USE ONLY
PWD Case Number: Case Status: Validity Period: to
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File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
File Modified | 0000-00-00 |
File Created | 0000-00-00 |