Nonimmigrant Worker Information FormU.S. Department of Labor Wage and Hour DivisionThis report is authorized by certain Immigration and Nationality Act provisions. 8 U.S.C. 247247 1182(n)(2)(A), 1182(n)(2)(G), and 1182(t)(3)(A). The information provided on this form will assist the U.S. Department of Labor (DOL) in determining whether the named employer of H-1B, H-1B1 or E-3 nonimmigrant(s) has committed a violation of provisions of the applicable nonimmigrant program. Instructions: Please provide as much of the requested information as possible. Your identity will be kept confidential to the extent provided by the law. 5 U.S.C. 247 552(b)(7)(D). If necessary, attach additional sheets to this form if you need more space to answer. If you do not understand a term, or need assistance in the completion of this form, please contact the U.S. Department of Labor Wage and Hour Division (WHD) at 1-866-4USWAGE (1-866-487-9243). Once you complete this form, please mail or otherwise deliver it to the WHD office that has jurisdiction over the physical location of the employer. For WHD office locations visit http://www.dol.gov/contacts/whd/america2.htm . After you submit this form, a representative from the Wage and Hour Division may contact you if further information is necessary to initiate an investigation. The Immigrant and Employee Rights Section of the U.S. Department of Justice, Civil Rights Division, handles complaints alleging failure to offer employment to an equally or better qualified U.S. worker or a misrepresentation regarding such offer(s) of employment. If your allegations concern such matters, please file your complaint with the Immigrant and Employee Rights Section at https://www.justice.gov/crt/filing-charge. You may also call the toll-free Worker Hotline at 1-800-255-7688 or 1-800-237-2515 (TTY). Page 1- Continued on next page - Form WH-4 REV 10/2018 1. Person Submitting Information (please print) First Name Middle Initial Last NameMailing Address: Number, Street, Apt., or P.O. Box No. State City ZIP Code Email Address: Telephone Number (including area code) 2. Status. Please identify the status under which you are filing this complaint. Nonimmigrant Worker (please choose visa classification below) H-1B H-1B1 E-3 U.S. Worker Job Applicant Date of Application:OMB NO: 1205-0310 Expires: 10/31/2021 Competitor Business (please specify business name) Federal Government Agency (please specify agency) State or Local Government Agency (please specify agency) Community or Service Organization (please specify organization) Other (please specify) Best means to contact you: American LegalNet, Inc. www.FormsWorkFlow.com 3. Information on Company or Entity Committing Alleged Violation(s). Please provide the information below on the company or entity that committed the alleged nonimmigrant program violation(s). Name of Company/Entity: Representative to be Contacted: Telephone Number (including area code):- Continued on next page - Page 2Form WH-4 REV 10/2018 Job Title/Occupation:If the company or entity named above employed you, please identify the dates of employment and your job title/occupation.Did the company or entity identified above place nonimmigrant workers with another company or entity? State City ZIP Code Address: Number, Street, Apt., or P.O. Box No. Dates of Employment: to I don't know No YesIf yes, please identify the name of the company or entity where nonimmigrant workers were placed. American LegalNet, Inc. www.FormsWorkFlow.com Page 3Form WH-4 REV 10/2018 Employer failed to provide fringe benefits to nonimmigrant worker(s) equivalent to those provided to U.S. worker(s) (e.g., cash bonuses, stock options, paid vacations and holidays, health benefits, insurance, retirement and saving plans). 4. Description of Alleged Violation(s)Please check the appropriate box(es) that best describe the alleged violation(s) of the applicable nonimmigrant worker provisions of the Immigration and Nationality Act which you believe have occurred. Employer supplied incorrect or false information on the Labor Condition Application (LCA). Employer failed to pay nonimmigrant worker(s) the higher of the prevailing or actual wage. Employer failed to pay nonimmigrant worker(s) for time off due to a decision by the employer (e.g., for lack of work) or for time needed by the nonimmigrant worker(s) to acquire a license or permit. Employer made deductions from nonimmigrant worker's wage (e.g., for nonimmigrant petition processing; for food and housing expenses when the nonimmigrant worker is traveling on the employer's business; for tools and equipment necessary to perform employer's work) that caused the wages paid to fall below the nonimmigrant worker's required wage. Employer does not afford nonimmigrant worker(s) working conditions (hours, shifts, and vacation periods) on the same basis as it does U.S. worker(s), or the employment of nonimmigrant worker(s) adversely affects the working conditions of U.S. worker(s). Employer failed to comply with 223no strike/lockout224 requirement by: 1) placing or contracting out nonimmigrant worker(s) during the validity period of the LCA to any place of employment where there is a labor dispute; 2) failing to notify the DOL, within 3 working days of the occurrence, of such a labor dispute; or 3) using an LCA for nonimmigrant worker(s) to work at a site before the DOL has determined that a labor dispute has ended. Employer failed to provide employees or their collective bargaining representative, either by hard copy posting or electronically, notice of its intentions to hire nonimmigrant worker(s), or has failed to provide nonimmigrant worker(s) with a copy of the LCA. Employer required nonimmigrant worker(s) to pay all or any part of the scholarship and training fee (ACWIA fee). Employer imposed an illegal penalty (as opposed to liquidated damages permissible under state law) on nonimmigrant worker(s) for ceasing employment with the employer prior to a date agreed upon by the nonimmigrant worker and the employer. Employer retaliated or discriminated against an employee, former employee, or job applicant for disclosing information, filing a complaint, or cooperating in an investigation or proceeding about a violation of the applicable nonimmigrant program laws and regulations (i.e., whistleblower). Employer failed to maintain and make available for public examination the LCA and necessary documents at the employer's principal place of business or worksite. H-1B dependent/willful violator employer displaced U.S. worker(s) in its own workforce within 90 days before or after filing H-1B visa petitions. H-1B dependent/willful violator employer placed H-1B workers(s) at another employer's worksite where U.S. workers have been displaced within 90 days before or after placement of the H-1B worker(s), and/or has failed to inquire of the second employer whether it has or intends to displace U.S. worker(s) within 90 days before or after placement of the H-1B worker(s). H-1B dependent/willful violator employer failed to recruit U.S. worker(s) for jobs for which H-1B worker(s) are sought. H-1B dependent/willful violator employer failed to hire a U.S. worker who applied and was equally or better qualified for the job for which the H-1B worker was sought. Allegations of failure to offer employment to an equally or better qualified U.S. worker, or a misrepresentation regarding such offer(s) of employment, may be filed with the Immigrant and Employee Rights Section of the U.S. Department of Justice, Civil Rights Division at https://www.justice.gov/crt/filing-charge. You may also call the toll-free Worker Hotline at 1-800-255-7688 or 1-800-237-2515 (TTY). Other: Note: The following items do not apply to H-1B1 or E-3 workers. An H-1B dependent employer is one who employs 25 or fewer full-time equivalent employees employed in the U.S. and at least eight H-1B nonimmigrant workers; or 26-50 full-time equivalent employees employed in the U.S. and at least 13 H-1B nonimmigrant workers; or 51 or more full-time equivalent employees employed in the U.S. and 15% or more are H-1B nonimmigrant workers. INA 212(n)(3)(A), 20 CFR 655.736(a). An H-1B