Form ETA-9141 - Appendix A - Request for Additional Worksites

O MB Approval: XXXX-XXXX

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 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 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 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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