Form H-1b Eta 9089 - Employee Information Form
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1ETA 9089 EMPLOYEE INFORMATION FORM
This form is intended to provide information about a UNCW employee (current or prospective) who will be the beneficiary
of a permanent resident application, via ETA Form 9089 (labor certification).
1.Name_____________________________________________________________________________________________
Family Name (Last Name)
(First)
(Middle)
2. Date of Birth: (mo/day/year) _________________________ 3. Country of Birth:________________________________
4. Country of Citizenship:______________________________ 5. Province/State of Birth:___________________________
6. Country of Legal Permanent Residence___________________ 7. Email Address________________________________
8. Current Mailing Address:_____________________________________________________________________________
9. Address Outside of U.S. (required):____________________________________________________________________
10. U.S. Social Security #___________________________ 11. Home phone number:_______________________________
(if none, write “none”)
12. Currently in the U.S.? _______yes _______no
13. Currently employed at UNCW? ______yes ______no
14. If currently in the U.S., answer the following:
a. Date of last arrival in the U.S. (mo/date/year)__________________ b. I-94#_________________________________
c. Current nonimmigrant status (i.e. J-1, F-1, TN):________________ d. Date current status expires________________
15. Has UNCW ever filed an immigrant petition on your behalf? _______yes _______no
If yes, give details:_________
___________________________________________________________________________________________________
16. Are you currently in exclusion or deportation proceedings? _______yes _______no
17. Have you had H-1B status in the past 6 years? _______yes _______no
If yes, give dates and names of employer(s):
___________________________________________________________________________________________________
18. Do you have visa dependents (spouse or children)?
If yes, please answer the following:
Name
Relationship
Date of Birth
Currently
Current Status
In U.S.?
__________________________ ___ _________________ _______________
__________
_________________
19. For your employment history over the past 5 years, please submit: job description and name and phone number of your
supervisor for each job you’ve had. (Attach on separate sheet.)
I attest that the above information is true and give the Office of International Programs the authority to use this information
when filing a labor certification and Form I-140 on my behalf.
__________________________________________________________
____________________________
Signature of Beneficiary
Date
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