Please return to: Applicant Services Unit P.O. Box 27625 Raleigh, NC 27611 Phone: 919-733-4896 Fax: 919-733-3010 EMPLOYMENT SECURITY COMMISSION OF NORTH CAROLINA Please check one: ___ H-1B Professional ___ Perm (incl. nurses) ___ H-2B RALEIGH, NORTH CAROLINA 27611 PREVAILING WAGE REQUEST FORM Allow up to 14 business days for processing H-1B/Perm and up to 30 days for H-2B. A. To be completed by Employer or Employer Representative 1. Name of Employer (Full name of organization): 3. Telephone (Include Area Code): 2. Physical Address of Job Site: (Include street, city, state and zip code) 4. Nature of Employer’s Business: 6. Suggested OES/SOC Code: (If Known) 5. Job Title: 7. Is This a Renewal? Yes No If yes, attach previous determination. 8. Total Hrs. Per Week: 9. Rate of Pay: $___________________per _____________ 10. Describe fully the job to be performed (Duties): The duties must begin in this section. If additional space is needed, attachments may be used. 11. Special Requirements: (Do not include alternate education and experience requirements) 12: State in detail the minimum education, training, and experience; not the foreign national’s qualifications: 13: Supervise Others? Yes Number Supervised: Education (no. of years) Grade School High School Requestor’s Name and Address: Experience Yrs. Mos. Training Yrs. Mos. College College degree (specify field of study): No Tel. No: _______________________________ Type of Training Required: Fax No: _______________________________ B. FOR ESC USE ONLY Case Number: ______________________________________________ O*NET/SOC Code: _____________________________________ O*NET/SOC Title: DOT/SOC Code: _____________________________________ ________________________________________________________________________________________________________ Wage Determination: ________________________per_________________ Level 1 _______________ Level 2 _______________ Level 3 _______________ Level 4 _______________ _____Alternate Survey _____Collective Bargaining Agreement: ______________________per_________________ ____________________________________________Validity Period_______________________________________________________________________ OES Wage Determinations issued on or after July 1, 2008 are valid through June 30, 2009. OES Wage Determinations issued in April, May, or June of 2009 are valid for 90 days beginning with the date of issuance. OES Wage Determinations issued on or after July 1, 2009 are valid through June 30, 2010. Employers must file their applications, or begin their recruitment within the validity period. The employer is not required to submit this form with the application/attestation, but is required to retain this document for five (5) years from the date of filing. Published surveys valid for at least 90 days, or until next publication, but not to exceed one year. SCA/DBA/Employer-conducted surveys valid for 90 days. Collective Bargaining Agreements valid for at least 90 days or until next renewal, but not to exceed one year from date of issuance. ESC Representative ______________________________________________________________ Date _________________________________________ NCSES FLC-PW-4 (revised Jan 09) American LegalNet, Inc. www.FormsWorkflow.com