PREVAILING WAGE REQUEST Submit typed form to: Foreign Labor Certification 1000 S.W. Jackson Street, Suite 100 Topeka, Kansas 66612 Phone: (785) 291-3470 FAX: (785) 296-3141 mailto:jsmutny@kansascommerce.com Please Check One: H-1B Professional/Perm H-2B Temp Non-Agricultural H-2A Temp Agricultural Appeal If the job is covered by collective agreement, DO NOT complete this form. The employer must use the negotiated wage. 1. Name of Employer: 2. Address of Employer: City: County: 3. Location of Worksite: 4. Nature of Employer’s Business Activity: Telephone Number: State: Zip: 5. Title of Job Being Filled: 6. Position title that supervises this position: 7. Basic Hours of Work per Week: Basic Rate of Pay Offered: $ per Overtime Required: Yes No 8. Suggested OES – SOC code: 9. Describe fully the job duties to be performed. (Start with the most important one first) See attached for more. Yes 10. Supervision: Yes No If Yes, how many? 11. Are there any working conditions that affect the rate of pay? Yes No If Yes, what are they? 12. State in detail the MINIMUM education (specify degree and major field of study). 13. Training: Yes 14. Experience: Yes No No No education required. If Yes, please explain. If Yes, please explain. 15. Other Special Requirements for the job: Yes 16. Mr. Ms. Name of Requester: Mailing Address: City: Telephone: E-Mail: No Date: State: Fax: Zip: ATTENTION: Please allow at least 14 days processing time form date of receipt. The determination will be faxed whenever possible. Form must be filled out completely before a determination can be made. FLC Data Center: http://www.flcdatacenter.com/ American LegalNet, Inc. www.FormsWorkflow.com