Form ETA-9141C Application for Prevailing Wage Determination

O MB Approval: 1205-0534

Expiration Date: 10/31/2021

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

Indicate the type of visa classification supported by this application (Write classification symbol): *

B. Employer Point-of-Contact Information

Important Note: The information contained in this section is for an employee authorized to act on behalf of the employer. The information in this section must be different from the attorney or agent information listed in Section D, except when an attorney listed in Section D is an employee of the employer.

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 *	9. Postal Code *
10. Country *				11. Province §
12. Telephone Number *	13. Extension §		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 *	7. Postal Code *
8. Country *	9. Province §
10. Telephone Number *	11. Extension §
12. Federal Employer Identification Number (FEIN from IRS) *	13. NAICS Code *

D. Attorney or Agent Information (if applicable)

1. Indicate the type of representation for the employer in the filing of this application * If D.1 is “Attorney” or “Agent” the remainder of this section is required				 Attorney  Agent  None
2. Attorney or Agent’s Last (family) Name §		3. First (given) Name §		4. Middle Name(s) §
5. Address 1 §
6. Address 2 (apartment/suite/floor and number) §
7. City §			8. State §		9. Postal Code §
10. Country §			11. Province (if applicable) §
12. Telephone Number §	13. Extension §		14. Law Firm/Business E-Mail Address §
15. Law Firm/Business Name §			16. Law Firm/Business FEIN §

______________________________________________________________________________________________________

E. Job Opportunity Information

a. Job Description

1. Job Title *
Suggested SOC Occupational Code *			2a. Suggested SOC Occupation Title *
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  No	6a. If “Yes” to question 6, please provide details of the travel required, such as area(s), frequency and nature of the travel. §

b. Minimum Job Requirements

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 U.S. 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)
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. §
Is training for the job opportunity required? *			 Yes  No
3a. If “Yes” in question 3, specify the number of months of training required. §	3b. Indicate the field(s)/name(s) of training required. § (May list more than one related field and more than one type)
Is employment experience required? *			 Yes  No
4a. If “Yes” in question 4, specify the number of months of experience required. §	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

Worksite Address *
Worksite Address
City *	State *	Postal Code *
 Yes  No
6a. If “Yes” in question 6, identify the specific geographic place(s) of employment 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. §

F. Prevailing Wage Determination

FOR OFFICIAL GOVERNMENT USE ONLY
1. PWD Tracking Number	2. PW Receipt Date
3. SOC Code:	a. SOC Occupation Title:
While all prevailing wages are issued at the six digit SOC code level, O*NET includes extended eight digit occupations. If applicable, the O*NET eight-digit extension code is listed below.
b. O*NET Code:	c. O*NET Occupation Title:
When the job opportunity represents a combination of occupations, listed below are the other occupations.
d. O*NET Code:	e. O*NET Occupation Title:
4. Prevailing wage: (based on the primary worksite location. on the minimum job requirements for the position. $___________.______per  Hour  Year
Prevailing wage source (Choose only one)  CNMI Governor’s Survey  OES (Guam)  OES (National Adjusted)
6. Additional Notes Regarding Wage Determination:
7. Determination date:	8. Expiration date:

For the public burden statement, please see Form ETA-9141C, General Instructions.

Form ETA-9141C FOR DEPARTMENT OF LABOR USE ONLY Page 1 of 5

PW Tracking Number: __________________ Case Status: __________________ Determination Date: _____________ Validity Period: _____________ to _____________