H-1B Nonimmigrant Information

• Legal Form Number: WH-4
• Issuer: Wage and Hour Division
• Section: U.S. Department of Labor

Nonimmigrant Worker

Information Form

U.S. Department of Labor

Wage and Hour Division

This report is authorized by certain Immigration and Nationality Act provisions. 8 U.S.C. §§ 1182(n)(2)(A), 1182(n)(2)(G), and 1182(t)(3)(A). The information provided on this

form will assist the U.S. Department of Labor (DOL) in determining whether the named employer of H-1B, H-1B1 or E-3 nonimmigrant(s) has committed a violation of

provisions of the applicable nonimmigrant program.

Instructions: Please provide as much of the requested information as possible. Your identity will be kept confidential to the extent provided by the law. 5 U.S.C. § 552(b)(7)

(D). If necessary, attach additional sheets to this form if you need more space to answer. If you do not understand a term, or need assistance in the completion of this

form, please contact the U.S. Department of Labor Wage and Hour Division (WHD) at 1-866-4USWAGE (1-866-487-9243). Once you complete this form, please mail or

otherwise deliver it to the WHD office that has jurisdiction over the physical location of the employer. For WHD office locations visit http://www.dol.gov/contacts/whd/

america2.htm. After you submit this form, a representative from the Wage and Hour Division may contact you if further information is necessary to initiate an investigation.

The Immigrant and Employee Rights Section of the U.S. Department of Justice, Civil Rights Division, handles complaints alleging failure to offer employment to an equally or

better qualified U.S. worker or a misrepresentation regarding such offer(s) of employment. If your allegations concern such matters, please file your complaint with the

Immigrant and Employee Rights Section at https://www.justice.gov/crt/filing-charge. You may also call the toll-free Worker Hotline at 1-800-255-7688 or 1-800-237-2515

(TTY).

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Form WH-4

REV 10/2018

1. Person Submitting Information (please print)

First Name Middle Initial Last Name

Mailing Address:

Number, Street, Apt., or P.O. Box No.

StateCity ZIP Code

Email Address:

Telephone Number (including area code)

2. Status. Please identify the status under which you are filing this complaint.

Nonimmigrant Worker (please choose visa classification below)

H-1B H-1B1 E-3

U.S. Worker

Job Applicant

Date of Application:

OMB NO: 1205-0310

Expires: 12/31/2024

Competitor Business (please specify business name)

Federal Government Agency (please specify agency)

State or Local Government Agency (please specify agency)

Community or Service Organization (please specify organization)

Other (please specify)

Best means to contact you: