Form 9141 Online – Fill Out and Use This PDF

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

5.

City *

6.

State *

7. Postal code *

8.

Country *

9.

Province (if applicable)

10.

Telephone number *

11.

Extension

12.

Federal Employer Identification Number (FEIN from IRS) *

13.

NAICS code (must be at least 4-digits) *

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

 Yes

 No

Contract (SCA) Acts? *

 DBA  SCA

Form ETA-9141

FOR DEPARTMENT OF LABOR USE ONLY

Page 1 of 4

D. Wage Processing Information (cont.)

4.

Is the employer requesting consideration of a survey in determining the prevailing wage? *

 Yes  No

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:

_______

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

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 _______________

1a.

If “Other degree” in question 1, specify the 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

3.

Is training for the job opportunity required? *

 Yes

 No

3a. If “Yes” in question 3, specify the number of

3b.

Indicate the field(s)/name(s) of training required §

months 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

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? *

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) 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