1. Name of Alien. (Family name in CAPITAL letters, first name in small letters. Example DOE, john):

2. Name of Employer (Full name of organization):

3. Total Number of Employees:

4. Gross Annual Revenue/Sales (approximately):

5. Address where alien will work (including street address, city, county, state and zip code)

6. Nature of Employer's Business Activity:

7. Alien's Job Title:

8. Total Hours per week:

Basic:      Overtime:

9. Work Schedule Hourly:

10. Basic rate of pay:

$   per

11. Describe fully the Job to be performed:

12. Title of Alien's Immediate Supervisor:

13. Number of employees that alien will supervise:

14. Title of Alien's Subordinates:

15. State in detail the minimum education, training, experience and other special requirements for a worker to perform satisfactorily the job duties specified:

Number of Years Education Required:

Pre-college  College

College Degree Required (specify)

Major Field of Study:

Number of Years Training Required:

Years   Months

Type of Training

Job Offered:

Years   Months

Related Occupation:

Years   Months

Related Occupations (specify):

Other Special Requirements:

16. Employer or Employers Representative:

Telephone Number

Fax Number

E-mail Address 
Note: we MUST have a valid email from you or we will not receive your request!

17. Address of Employer (if different from #5)  or Employers Representative (including street address, city, county, state and zip code)