Form ETA-9141 - Ap Form ETA-9141 Appendix A, Request for Additional Worksit

Application for Prevailing Wage Determination

New - Form ETA-9141 Appendix A

Prevailing Wage Determination

OMB: 1205-0508

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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 *


  1. County: ________________ 2. State: ______ OR 3. BLS Area: _________________________________________


For Official Government Use Only

SOC Code: SOC Title:

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 *


  1. County: ________________ 2. State: ______ OR 3. BLS Area: _________________________________________


For Official Government Use Only

SOC Code: SOC Title:

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 *


  1. County: ________________ 2. State: ______ OR 3. BLS Area: _________________________________________


For Official Government Use Only

SOC Code: SOC Title:

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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