U.S. DEPARTMENT OF LABOR EMPLOYMENT AND TRAINING ADMINISTRATION APPLICATION FOR ALIEN EMPLOYMENT CERTIFICATION OMB Approval No. 1205-0015 PART B. STATEMENT OF QUALIFICATIONS OF ALIEN FOR ADVICE CONCERNING REQUIREMENTS FOR ALIEN EMPLOYMENT CERTIFICATION: If the alien is in the U.S., contact nearest office of the United States Citizenship and Immigration Service. If the alien is outside the U.S., contact nearest U.S. Consulate. IMPORTANT: READ ATTACHED INSTRUCTIONS BEFORE COMPLETING THIS FORM. Print legibly in ink or use a typewriter. If you need more space to fully answer any questions on this form, use a separate sheet. Identify each answer with the number of the corresponding question. Sign and date each sheet. 1. Name of Alien (Family name in capital letters) First name Middle name Maiden name Expires: 06/30/2017 2. Present Address (No., Street, City and Town, State or Province and ZIP code) Country 3. Type of Visa (If in U.S.) 4. Alien's Birth date (Month, Day, Year) 5. Birthplace (City or Town, State or Province) Country 6. Present Nationality or Citizenship (Country) 7. Address in the United States Where Alien Will Reside 8. Name and Address of Prospective Employer if Alien has job offer in U.S. 9. Occupation in which Alien is Seeking Work 10. "X" the appropriate box below and furnish the information required for the box marked City in Foreign Country a. Alien will apply for a visa abroad at the American Consulate in City b. Alien is in the United States and will apply for adjustment of status to that of a lawful permanent resident in the office of the United States Citizenship and Immigration Service at Field of Study FROM Month Year Month TO Year Degrees or Certificates Received State Foreign Country 11. Names and Addresses of Schools, ColLeges and Universities Attended (include trade or vocational training facilities) SPECIAL QUALIFICATIONS AND SKILLS 12. Additional Qualifications and Skills Alien Possesses and Proficiency in the use of Tools, Machines or Equipment Which Would Help Establish if Alien Meets Requirements for Occupation in Item 9. 13. List Licenses (Professional, journeymen, etc.) 14. List Documents Attached Which are Submitted as Evidence that Alien Possesses the Education, Training, Experience, and Abilities Represented Endorsements DATE REC. DOL O.T. & C. (Make no entry in this section - FOR Government Agency USE ONLY) (Items continued on next page) ETA 750 Part B (Nov 2007) American LegalNet, Inc. www.FormsWorkFlow.com 15. WORK EXPERIENCE List all jobs held during the last three (3) years. Also, list any other jobs related to the occupation for which the alien is seeking certification as indicated in Item 9. a. NAME AND ADDRESS OF EMPLOYER NAME OF JOB DATE STARTED Month Year DATE LEFT Month Year KIND OF BUSINESS DESCRIBE IN DETAIL THE DUTIES PERFORMED, INCLUDING THE USE OF TOOLS, MACHINES OR EQUIPMENT NO. HOURS PER WEEK b. NAME AND ADDRESS OF EMPLOYER NAME OF JOB DATE STARTED Month Year DATE LEFT Month Year KIND OF BUSINESS DESCRIBE IN DETAIL THE DUTIES PERFORMED, INCLUDING THE USE OF TOOLS, MACHINES OR EQUIPMENT NO. HOURS PER WEEK c. NAME AND ADDRESS OF EMPLOYER NAME OF JOB DATE STARTED Month Year DATE LEFT Month Year KIND OF BUSINESS DESCRIBE IN DETAIL THE DUTIES PERFORMED, INCLUDING THE USE OF TOOLS, MACHINES OR EQUIPMENT NO. HOURS PER WEEK 16. DECLARATIONS DECLARATION OF ALIEN SIGNATURE OF ALIEN Pursuant to 28 U.S.C. 1746, I declare under penalty of perjury the foregoing is true and correct. DATE _________________________________________________________________________________________________________________________________________ E-mail address of Alien: AUTHORIZATION OF AGENT OF ALIEN SIGNATURE OF ALIEN I hereby designate the agent below to represent me for the purposes of labor certification and I take full responsibility for accuracy of any representations made by my agent. DATE NAME OF AGENT (Type or print) ADDRESS OF AGENT (No., Street, City, State, ZIP code) __________________________________________________________________________________________ E-mail address of Agent:: OMB No.: 1205-0015 OMB Burden Hours averages 1.5 hours. OMB Burden Statement: These reporting instructions have been approved under the Paperwork Reduction Act of 1995. Persons are not required to respond to this collection of information unless it displays a currently valid OMB control number. Obligations to reply are mandatory. (Title 8 U.S.C. §§ 1882, 1884, and 1188) Public reporting burden for this collection of information, which is to assist with planning and program management, includes the time to review instructions, search existing data sources, gather and maintain the data needed, and complete and review the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to the U.S. Department of Labor, Room C-4312, 200 Constitution Ave. NW, Washington, DC 20210. (Paperwork Reduction Project OMB 1205-0015.) American LegalNet, Inc. www.FormsWorkFlow.com PRIVACY ACT STATEMENT In accordance with the Privacy Act of 1974, as amended (5 U.S.C. 552a), you are hereby notified that the information provided herein is protected under the Privacy Act. The Department of Labor (DOL) is maintaining a System of Records titled Employer Application and Attestation File for Permanent and Temporary Alien Workers (DOL/ETA-7). Case files developed in processing labor certification applications, labor condition applications, or labor attestations, may be released to the employers which filed such applications, their representatives, and to named alien beneficiaries or their representatives, if requested, to review Employment and Training Administration (ETA) actions in connection with appeals of denials before the DOL Office of Administrative Law Judges and federal courts; to participating agencies such as the DOL Office of Inspector General, Employment Standards Administration. Department of Homeland Security ' s U.S, Citizenship and Immigration Services and Bureau of Immigration and Customs Enforcement, and Department of State in connection with administering and enforcing related immigration laws and regulations; and to the DOL Office of Administrative Law Judges and Federal Courts in connection with appeals of denials of labor certification requests, labor condition applications, and labor attestations. Further disclosures may be made under the following circumstances: