OMB Approval: 1205-0508 Expiration Date: 05/31/2019 Application for Prevailing Wage Determination Form ETA-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 * 4. Contact's job title * 5. Address 1 * 6. Address 2 7. City * 10. Country * 12. Telephone number * 15. E-Mail Address 13. Extension 8. State * 9. Postal code * 2. First (given) name * 3. Middle name(s) * 11. Province (if applicable) 14. Fax Number C. Employer Information 1. Legal business name * 2. Trade name/Doing Business As (DBA), if applicable § 3. Address 1 * 4. Address 2 5. City * 8. Country * 10. Telephone number * 12. Federal Employer Identification Number (FEIN from IRS) * 6. State * 7. Postal code * 9. Province (if applicable) 11. Extension 13. NAICS code (must be at least 4-digits) * D. Wage Processing Information 1. Is the employer covered by ACWIA? * Yes No 2. Is the position covered by a Collective Bargaining Agreement (CBA)? * 3. Is the employer requesting consideration of Davis-Bacon (DBA) or McNamara Service Contract (SCA) Acts? * Yes No Yes No DBA SCA Form ETA-9141 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: 1205-0508 Expiration Date: 05/31/2019 Application for Prevailing Wage Determination Form ETA-9141 U.S. Department of Labor D. Wage Processing Information (cont.) 4. Is the employer requesting consideration of a survey in determining the prevailing wage? * 4a. Survey Name: § 4b. Survey date of publication: § E. Job Offer Information a. Job Description: 1. Job Title * 2. Suggested SOC (ONET/OES) code * 3. Job Title of Supervisor for this Position (if applicable) § 4. Does this position supervise the work of other employees? * Yes No 4a. If "Yes", number of employees worker § will supervise: _______ 2a. Suggested SOC (ONET/OES) occupation title * Yes No 4b. If "Yes", please indicate the level of the employees to be supervised: Subordinate Peer 5. Job duties ­ Please provide a description of the duties to be performed with as much specificity as possible, including details regarding the areas/fields and/or products/industries involved. A description of the job duties to be performed MUST begin in this space. * 6. Will travel be required in order to perform the job duties? * Yes Form ETA-9141 6a. If "Yes", please provide details of the travel required, such as the area(s), frequency and nature of the travel. § 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: 1205-0508 Expiration Date: 05/31/2019 Application for Prevailing Wage Determination Form ETA-9141 U.S. Department of Labor E. Job Offer Information (cont.) 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.) 1a. If "Other degree" in question 1, specify the diploma/ 1b. Indicate the major(s) and/or field(s) of study required § (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 § Yes 3b. Indicate the field(s)/name(s) of training required § No (May list more than one related field and more than one type) 4. Is employment experience required? * 4a. If "Yes" in question 4, specify the number of months of experience required § Yes 4b. Indicate the occupation required § No 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 * 5. State/District/Territory * 4. County * 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", identify the geographic place(s) of employment indicating each metropolitan statistical area (MSA) or the independent city(ies)/township(s)/county(ies) (borough(s)/parish(es)) and the corresponding state(s) where work will be performed. If necessary, submit a second completed Form ETA-9141 with a listing of the additional anticipated worksites. Please note that wages cannot be provided for unspecified/unanticipated locations.§ Form ETA-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: 1205-0508 Expiration Date: 05/31/2019 Application for Prevailing Wage Determination Form ETA-9141 U.S. Department of Labor F. Prevailing Wage Determination FOR OFFICIAL GOVERNMENT USE ONLY 1. PW tracking number 3. SOC (ONET/OES) code 2. Date PW request received 3a. SOC (ONET/OES) occupation title 4. Prevailing wage $ __________ . ____ 4a. OES Wage level I II III IV N/A 5. Per: (Choose only one) Hour Week Bi-Weekly Month Year Piece Rate 5a. If Piece Rate is indicated in question 2, specify the wage offer requirements :* 6. Prevailing wage source (Choose only one) OES (All Industries) OES (ACWIA ­ Higher Education) CBA DBA SCA Other/Alternate Survey 6a. If "Other/Alternate Survey" in question 7, specify 7. Additional Notes Regarding Wage Determination 8. Determination date 9. Expiration date G.OMB Paperwork Reduction Act (1205-0508) 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