Employer-Provided Survey Attestations to Accompany H-2B Prevailing Wage Determination Request Based on a Non-OES Survey

• Legal Form Number: 9165
• Issuer: Employment and Training Administration
• Section: U.S. Department of Labor

OMB Approval: 1205-0516

Expiration Date: 02/28/2019Employer-Provided Survey Attestations to Accompany

H-2B Prevailing Wage Determination Request Based on a Non-OES Survey

Form ETA-9165

U.S. Department of Labor

Form ETA-9165 Page 1 of 3

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/. Those items marked with * are required. Items marked with § are required

if the condition listed is met.

A. Requestor Point-of-Contact Information (from Form ETA-9141, Section B)

1. Contact’s last (family) name *

2. First (given) name *

3. Middle name(s) *

4. Telephone number *

5. Extension

6.Fax Number

7. E-Mail Address

B. Employer Information (from Form ETA-9141, Section C)

1. Legal business name *

2. Trade name/Doing Business As (DBA), if applicable

3. Telephone number *

4. Extension

5. Federal Employer Identification Number (FEIN from IRS) *

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

C.Employer-Provided Survey Information

1. Survey name or title *

2.Is a collective bargaining agreement applicable to the job opportunity? *

Yes  No

3.Are professional sports league’s rules or regulations applicable to the job opportunity? *

Yes  No

4.

No data for the survey was collected by any H-2B employer or any H-2B employer’s agent,

representative, or attorney.

Yes  No

5.

Name of third party surveyor.

_____________________________________________________________________________________________

6.

Name of the official representative of the third party surveyor who approved the survey.

Contact’s last (family) name

____________________________________________

First (given) name

________________________________

7. The survey is based on wages paid 24 months or less before the date on which the survey

was submitted to ETA. *

Yes  No

8.This is the most recent edition of the survey. (Answer “yes” if this is the only edition of the survey.) *

Yes  No