Application for Prevailing Wage Determination

OMB Approval: 1205-0534
Expiration Date: 10/31/2021
                                                   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

 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 (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 *

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




Form ETA-9141C                                               FOR DEPARTMENT OF LABOR USE ONLY                                                                 Page 1 of 4
PW Tracking Number: __________________        Case Status: __________________       Determination Date: _____________    Validity Period: _____________ to _____________
OMB Approval: 1205-0534
Expiration Date: 10/31/2021
                                             Application for Prevailing Wage Determination
                                                            Form ETA-9141C
                                                         U.S. Department of Labor


a. Job Description (continued)
 3. Job Title of Supervisor for this Position §


 4. Does this position supervise the work of                 Yes          4a. If “Yes” to question 4, enter the number of
    other employees? *                                       No               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       6a. If “Yes” to question 6, please provide details of the travel required, such as area(s),
    perform the job duties? *                     frequency and nature of the travel. §
         Yes             No

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



 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. §




Form ETA-9141C                                         FOR DEPARTMENT OF LABOR USE ONLY                                                             Page 2 of 4
PW Tracking Number: __________________   Case Status: __________________    Determination Date: _____________   Validity Period: _____________ to _____________
OMB Approval: 1205-0534
Expiration Date: 10/31/2021
                                             Application for Prevailing Wage Determination
                                                            Form ETA-9141C
                                                         U.S. Department of Labor


b. Minimum Job Requirements (continued)

 3.    Is training for the job opportunity required? *                                                                    Yes  No
 3a. If “Yes” in question 3, specify the number of months                  3b. Indicate the field(s)/name(s) of training required. §
     of training required. §                                                   (May list more than one related field and more than one type)



 4. Is employment experience required? *                                                                                          Yes           No
 4a. If “Yes” in question 4, specify the number of months                  4b. Indicate the occupation(s) required. §
     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 *

 2.    Worksite Address

 3.    City *                                                                       4. State *                       5. Postal Code *


 6.    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. §




Form ETA-9141C                                         FOR DEPARTMENT OF LABOR USE ONLY                                                             Page 3 of 4
PW Tracking Number: __________________   Case Status: __________________    Determination Date: _____________   Validity Period: _____________ to _____________
OMB Approval: 1205-0534
Expiration Date: 10/31/2021
                                             Application for Prevailing Wage Determination
                                                            Form ETA-9141C
                                                         U.S. Department of Labor


E. 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)
      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 4 of 4
PW Tracking Number: __________________   Case Status: __________________    Determination Date: _____________   Validity Period: _____________ to _____________