State Of Connecticut Employment Security Division Prevailing Wage Request Form
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1Prevailing Wage Request Form
Please Return To:
State of Connecticut
Alien Labor Certification Unit
Employment Security Division
200 Folly Brook Blvd.
Prevailing Wage Request Form
Wethersfield, CT 06109
Rev. 7/09
Fax (860) 263-6039
NOTE: If the job is unionized and covered by a negotiated wage, use the negotiated wage and
DO NOT complete this Prevailing Wage Form, as the negotiated wage is the Prevailing wage.
1. Name of Employer
Telephone No.
2. Address Where Alien Will Work (include city, county, zip code)
3. Nature of Employer's Business Activity
4. Job Title Being Filled
5. Basic Hours Per Week
6. Basic Rate of Pay Offered (OPTIONAL) $
per
7. Describe Fully the Job Duties to Be Performed (List the MOST IMPORTANT Duty first)
8. Working conditions That Affect Rate of Pay
9. State, IN DETAIL, the MINIMUM Education (specify the Degree and Major Field of Study), Training, Experience and
Other Special Requirements for the job
10. Name of Requestor
Date
Address
Telephone (with area code)
FAX (with area code)
DO NOT WRITE BELOW THIS LINE - PREVAILING WAGE DETERMINATION BY DOL
___________________________________________________________________________________________________________________
Request No. ____________________________
O*NET Title _____________________________________________________________
O*NET CODE ________________________________
Skill Level _________________________________________________________
The Prevailing Wage for the job described above is _____________________ per ________________
Source: OES Survey_____
Service Contract Act _____
Davis Bacon Act _____
Other _________________________________
This rate is valid for:
date issued through 12/31/2009
90 days from date of this determination
Agency Official ___________________________________________________ Tel # (860) 263-6020
Date _____________________________
PRINT FORM
CLEAR FORM
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Parent category: Business