Form ETA-9141 "Application for Prevailing Wage Determination"

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This is a legal form that was released by the U.S. Department of Labor - Employment & Training Administration and used country-wide. Check the official instructions before completing and submitting the form.

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Download Form ETA-9141 "Application for Prevailing Wage Determination"

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OMB Approval: 1205-0508
Expiration Date: 10/31/2019
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 *
2. First (given) name *
3. Middle name(s) *
4. Contact’s job title *
5. Address 1 *
6. Address 2
7. City *
8. State *
9. Postal code *
10. Country *
11. Province (if applicable)
12. Telephone number *
13. Extension
14. Fax Number
15. E-Mail Address
C. Employer Information
1. Legal business name *
2. Trade name/Doing Business As (DBA), if applicable
§
3. Address 1 *
4. Address 2
5. City *
6. State *
7. Postal code *
8. Country *
9. Province (if applicable)
10. Telephone number *
11. Extension
12. Federal Employer Identification Number
13. NAICS code
(FEIN from IRS) *
(must be at least 4-digits) *
D. Wage Processing Information
 Yes  No
1. Is the employer covered by ACWIA? *
 Yes  No
2. Is the position covered by a Collective Bargaining Agreement (CBA)? *
 Yes  No
3. Is the employer requesting consideration of Davis-Bacon (DBA) or McNamara Service
 DBA  SCA
Contract (SCA) Acts? *
Form ETA-9141
FOR DEPARTMENT OF LABOR USE ONLY
Page 1 of 4
PW Tracking Number:___________________ Case Status: __________________ Validity Period: ______________ to _______________
OMB Approval: 1205-0508
Expiration Date: 10/31/2019
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 *
2. First (given) name *
3. Middle name(s) *
4. Contact’s job title *
5. Address 1 *
6. Address 2
7. City *
8. State *
9. Postal code *
10. Country *
11. Province (if applicable)
12. Telephone number *
13. Extension
14. Fax Number
15. E-Mail Address
C. Employer Information
1. Legal business name *
2. Trade name/Doing Business As (DBA), if applicable
§
3. Address 1 *
4. Address 2
5. City *
6. State *
7. Postal code *
8. Country *
9. Province (if applicable)
10. Telephone number *
11. Extension
12. Federal Employer Identification Number
13. NAICS code
(FEIN from IRS) *
(must be at least 4-digits) *
D. Wage Processing Information
 Yes  No
1. Is the employer covered by ACWIA? *
 Yes  No
2. Is the position covered by a Collective Bargaining Agreement (CBA)? *
 Yes  No
3. Is the employer requesting consideration of Davis-Bacon (DBA) or McNamara Service
 DBA  SCA
Contract (SCA) Acts? *
Form ETA-9141
FOR DEPARTMENT OF LABOR USE ONLY
Page 1 of 4
PW Tracking Number:___________________ Case Status: __________________ Validity Period: ______________ to _______________
OMB Approval: 1205-0508
Expiration Date: 10/31/2019
Application for Prevailing Wage Determination
Form ETA-9141
U.S. Department of Labor
D. Wage Processing Information (cont.)
 Yes  No
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 *
2a. Suggested SOC (ONET/OES) occupation title *
3. Job Title of Supervisor for this Position (if applicable)
§
4. Does this position supervise the work of other employees? *
4a. If ”Yes”, number of employees worker
§
 Yes  No
will supervise:
_______
 Subordinate
 Peer
4b. If “Yes”, please indicate the level of the employees to be supervised:
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
6a. If “Yes”, please provide details of the travel required, such as the area(s),
perform the job duties? *
frequency and nature of the travel.
§
 Yes
 No
Form ETA-9141
FOR DEPARTMENT OF LABOR USE ONLY
Page 2 of 4
PW Tracking Number:___________________ Case Status: __________________ Validity Period: ______________ to _______________
OMB Approval: 1205-0508
Expiration Date: 10/31/2019
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
§
 Yes
 No
2. Does the employer require a second U.S. diploma/degree? *
2a. If “Yes” in question 2, indicate the second U.S. diploma/degree and the major(s) and/or field(s) of study required
§
 Yes
 No
3. Is training for the job opportunity required? *
3a. If “Yes” in question 3, specify the number of
3b. Indicate the field(s)/name(s) of training required
§
(May list more than one related field and more than one type)
months of training required
§
 Yes
 No
4. Is employment experience required? *
4a. If “Yes” in question 4, specify the number of
4b. Indicate the occupation required
§
months of experience required
§
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 *
4. County *
5. State/District/Territory *
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 _______________
OMB Approval: 1205-0508
Expiration Date: 10/31/2019
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
2. Date PW request received
3. SOC (ONET/OES) code
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)
CBA
DBA
SCA
OES (ACWIA – Higher Education)
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
Act, Section 101). Public reporting burden for this collection of information is estimated to average 55 minutes per response, including the
time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the
collection of information. Send comments regarding this burden estimate to the Office of Foreign Labor Certification * U.S. Department of
Labor * Box 12 - 200 * 200 Constitution Ave., NW, * Washington, DC * 20210. Do NOT send the completed application to this address.
Form ETA-9141
FOR DEPARTMENT OF LABOR USE ONLY
Page 4 of 4
PW Tracking Number:___________________ Case Status: __________________ Validity Period: ______________ to _______________
U.S. Department of Labor - Employment & Training Administration United States Federal Legal Forms United States Legal Forms

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