OMB Approval: 1205-0466 Expiration Date: 11/30/2011 Application for Prevailing Wage Determination ETA Form 9141 U.S. Department of Labor Please read and review the instructions carefully before completing this form and print legibly. A copy of the instructions can be found at http://www.foreignlaborcert.doleta.gov/. 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 7. City * 8. State * 10. Country * 11. Province 12. Telephone number * 13. Extension 9. Postal code * 14. Fax Number 15. E-Mail Address C. Employer Information 1. Legal business name * 2. Trade name/Doing Business As (DBA), if applicable § 3. Address 1 * 4. Address 2 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 (must be at least 4-digits) * D. Job Offer Information a. Job Description: 1. Job Title * 2. Suggested SOC (ONET/OES) code * ETA Form 9141 2a. Suggested SOC (ONET/OES) occupation title * FOR DEPARTMENT OF LABOR USE ONLY Page 1 of 4 PW Tracking Number:___________________ Case Status: __________________ Validity Period: ______________ to _______________ American LegalNet, Inc. www.FormsWorkFlow.com OMB Approval: 1205-0466 Expiration Date: 11/30/2011 Application for Prevailing Wage Determination ETA Form 9141 U.S. Department of Labor a. Job Description (continued) 3. Number of hours of work per week * Basic: _______ 3a. Hourly Work Schedule * Overtime*: _______ A.M. (h:mm): ___ : ____ P.M. (h:mm): ___ : ____ 4. Job Title of Supervisor for the Workers (if applicable) § 5. Does this position supervise the work of other employees? * Yes No 5a. If yes, number of employees worker § will supervise (if applicable) _______ 6. Job duties – A description of the job duties to be performed MUST begin in this space. If necessary, add attachment to continue and complete description. * 7. Will travel be required in order to perform the job duties? * Yes No 8. Are there any other working conditions that affect the rate of pay? * Yes ETA Form 9141 7a. If “Yes”, please explain the travel requirements: § 8a. If “Yes”, please specify the working conditions. § No FOR DEPARTMENT OF LABOR USE ONLY Page 2 of 4 PW Tracking Number:___________________ Case Status: __________________ Validity Period: ______________ to _______________ American LegalNet, Inc. www.FormsWorkFlow.com OMB Approval: 1205-0466 Expiration Date: 11/30/2011 Application for Prevailing Wage Determination ETA Form 9141 U.S. Department of Labor 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.) 1b. Indicate the major(s) and/or field(s) of study required § 1a. If “Other degree” in question 1, specify the diploma/ (May list more than one related major and more than one field) degree required § 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 § 3. Is training for the job opportunity required? * 3a. If “Yes” in question 3, specify the number of months of training required § 4. Is employment experience required? * 4a. If “Yes” in question 4, specify the number of months of experience required § Yes No 3b. Indicate the field(s)/name(s) of training required § (May list more than one related field and more than one type) Yes No 4b. Indicate the occupation required § 5. Special Requirements - List specific skills, licenses/certificates/certifications, and requirements of the job opportunity. * c. Place of Employment Information: 1. Worksite address 1 * 2. Address 2 3. City * 4. County * 5. State/District/Territory * 6. Postal code * 7. Will work be performed in multiple worksites within an area of intended Yes No employment or a location(s) other than the address listed above? * 7a. If Yes in question 7, identify the geographic place(s) of employment with as much specificity as possible. If necessary, submit an attachment to continue and complete a listing of all anticipated worksites. § ETA Form 9141 FOR DEPARTMENT OF LABOR USE ONLY Page 3 of 4 PW Tracking Number:___________________ Case Status: __________________ Validity Period: ______________ to _______________ American LegalNet, Inc. www.FormsWorkFlow.com OMB Approval: 1205-0466 Expiration Date: 11/30/2011 Application for Prevailing Wage Determination ETA Form 9141 U.S. Department of Labor E. Prevailing Wage Determination FOR OFFICIAL GOVERNMENT USE ONLY 1. PW tracking number 3. SOC (ONET/OES) code 4. Prevailing wage 2. Date PW request received 3a. SOC (ONET/OES) occupation title 4a. Wage level $ __________ . ____ I II III IV N/A 5. Per: (Choose only one) Hour Week Bi-Weekly Month Year 5a. If Piece Rate is indicated in question 2, specify the wage offer requirements :* Piece Rate 6. Prevailing wage source (Choose only one) OES CBA DBA SCA Other/Alternate Survey 6a. If “Other/Alternate Survey” in question 6, specify 7. Additional Notes Regarding Wage Determination 8. Determination date 9. Expiration date F. OMB Paperwork Reduction Act (1205-0466) k Persons are not required to respond to this collection of information unless it displays a currently valid OMB control number. Respondent’s reply to these reporting requirements is mandatory to obtain the benefits of temporary employment certification (Immigration and Nationality Act, Section 101). Public reporting burden for this collection of information is estimated to average 55 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate to the Office of Foreign Labor Certification * U.S. Department of Labor * Room C4312 * 200 Constitution Ave., NW * Washington, DC * 20210. Do NOT send the completed application to this address. ETA Form 9141 FOR DEPARTMENT OF LABOR USE ONLY Page 4 of 4 PW Tracking Number:___________________ Case Status: __________________ Validity Period: ______________ to _______________ American LegalNet, Inc. www.FormsWorkFlow.com