Form ETA 9141C ETA 9141C Application for Prevailing Wage Determination

O MB Approval: 1205-0534

Expiration Date: 09/30/2019

Application for Prevailing Wage Determination

Form ETA-9141C

U.S. Department of Labor

IMPORTANT: Employers and authorized preparers must read the general instructions carefully before completing the Form ETA-9141C. A copy of the instructions can be found at http://www.foreignlaborcert.doleta.gov/. If you are not submitting this electronically, please complete ALL required fields/items containing an asterisk (*) and any fields/items where a response is conditional as indicated by the section (§) symbol.

A. Employment-Based Visa Information

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 (apartment/suite/floor and number) §
7. City *				8. State *	9. Postal Code *
10. Country *				11. Province §
12. Telephone Number *	13. Extension §		14. Business Email Address *

C. Employer Information

1. Legal Business Name *
2. Trade Name/Doing Business As (DBA), if applicable §
3. Address 1 *
4. Address 2 (apartment/suite/floor and number) §
5. City *	6. State *	7. Postal Code *
8. Country *	9. Province §
10. Telephone Number *	11. Extension §
12. Federal Employer Identification Number (FEIN from IRS) *	13. NAICS Code *

D. Job Opportunity Information

a. Job Description

1. Job Title *
Suggested SOC Occupational Code *	2a. Suggested SOC Occupation Title *

a. Job Description (continued)

3. Job Title of Supervisor for this Position §
4. Does this position supervise the work of other employees? *		 Yes  No	4a. If “Yes” to question 4, enter the number of employees worker will supervise. §
4b. If “Yes” to question 4, 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  No	6a. If “Yes” to question 6, please provide details of the travel required, such as area(s), frequency and nature of the travel. §

b. Minimum Job Requirements

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 U.S. diploma/ degree required. §	1b. Indicate the major(s) and/or field(s) of study required. § (May list more than one related major and more than one field)
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. §

b. Minimum Job Requirements (continued)

Is training for the job opportunity required? *		 Yes  No
3a. If “Yes” in question 3, specify the number of months of training required. §	3b. Indicate the field(s)/name(s) of training required. § (May list more than one related field and more than one type)
Is employment experience required? *		 Yes  No
4a. If “Yes” in question 4, specify the number of months of experience required. §	4b. Indicate the occupation(s) required. §
Special Requirements - List specific skills, licenses/certificates/certifications, and requirements of the job opportunity. *

c. Place of Employment Information

Worksite Address *
Worksite Address
City *	State *	Postal Code *
Will work be performed in multiple worksites or locations other than the address listed above? *			 Yes  No
6a. If “Yes” in question 6, identify the specific geographic place(s) of employment where work will be performed. If necessary, submit a second completed Form ETA-9141C with a listing of the additional anticipated worksites. Please note that wages cannot be provided for unspecified/unanticipated locations. §

E. Prevailing Wage Determination

FOR OFFICIAL GOVERNMENT USE ONLY
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)  CNMI Governor’s Survey  OES (Guam)  OES (National Adjusted)
7. Additional Notes Regarding Wage Determination
8. Determination date			9. Expiration date

Public Burden Statement (1205-0534)

Persons are not required to respond to this collection of information unless it displays a currently valid OMB control number.  Public reporting burden for this collection of information is estimated to average 46 minutes to complete the form, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the needed data, and completing and reviewing the collection of information.  The obligation to respond to this data collection is required to obtain/retain benefits (Northern Mariana Islands U.S. Workforce Act of 2018, 48 U.S.C. 1806 et seq.).  Please send comments regarding this burden estimate or any other aspect of this information collection to the U.S. Department of Labor * Employment and Training Administration * Office of Foreign Labor Certification * 200 Constitution Ave., NW * Box PPII 12-200 * Washington, DC * 20210 or by email to ETA.OFLC.Forms@dol.gov. Please do not send the completed application to this address.

Form ETA-9141C FOR DEPARTMENT OF LABOR USE ONLY Page 5 of 5

PW Tracking Number: __________________ Case Status: __________________ Determination Date: _____________ Validity Period: _____________ to _____________