Prevailing Wage Request Form Please Return To: Alien Labor Certification Unit 200 Folly Brook Blvd. Wethersfield, CT 06109 Fax (860) 263-6039 State of Connecticut Employment Security Division Prevailing Wage Request Form Rev. 7/09 NOTE: If the job is unionized and covered by a negotiated wage, use the negotiated wage and DO NOT complete this Prevailing Wage Form, as the negotiated wage is the Prevailing wage. 1. Name of Employer 2. Address Where Alien Will Work (include city, county, zip code) Telephone No. 3. Nature of Employer's Business Activity 4. Job Title Being Filled 5. Basic Hours Per Week 6. Basic Rate of Pay Offered (OPTIONAL) $ per 7. Describe Fully the Job Duties to Be Performed (List the MOST IMPORTANT Duty first) 8. Working conditions That Affect Rate of Pay 9. State, IN DETAIL, the MINIMUM Education (specify the Degree and Major Field of Study), Training, Experience and Other Special Requirements for the job 10. Name of Requestor Address Telephone (with area code) FAX (with area code) Date DO NOT WRITE BELOW THIS LINE - PREVAILING WAGE DETERMINATION BY DOL ___________________________________________________________________________________________________________________ Request No. ____________________________ O*NET Title _____________________________________________________________ Skill Level _________________________________________________________ O*NET CODE ________________________________ The Prevailing Wage for the job described above is _____________________ per ________________ Source: OES Survey_____ This rate is valid for: Service Contract Act _____ Davis Bacon Act _____ Other _________________________________ date issued through 12/31/2009 90 days from date of this determination Agency Official ___________________________________________________ Tel # (860) 263-6020 Date _____________________________ American LegalNet, Inc. www.FormsWorkFlow.com