Form Eta 9089, Application For Permanent Employment Certification

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Alien Information for PERM
Please READ!
Please carefully answer ALL the questions in this questionnaire. The questions are taken directly
from Form ETA 9089, Application for Permanent Employment Certification (Sections J, K and
L). Your answers will be transferred to Sections J, K, and L of Form ETA 9089. The information
provided in the questionnaire must be true and correct. Knowingly furnishing wrong or false
information is a federal offense punishable by a fine or imprisonment up to five years, or both.
1.
Name: _________________________________________________________________
(Last Name)
(First/Given)
(Middle)
2.
Current Address (include street #, street, city, state & zip code):
________________________________________________________________________
________________________________________________________________________
____________________________________
Home Phone: (
) ________________
3.
Country of Citizenship: ____________________Country of Birth: __________________
4.
Date of Birth: ___________________ (MM/DD/YYYY)
5.
Current Status (H1B, J1, etc):_____________
6.
Alien Registration Number (A#, if applicable, found on EAD Card):_________________
7.
Number on the I-94: __________________________________________________
8.
Highest Level of Education relevant to the PERM position achieved:
Bachelor’s
Master’s
Doctorate
9.
Major Field of Study: ____________________________________
10.
Date Received Degree in Question 8: ______________________(MM/DD/YYYY)
11.
Institution Awarding Degree in Question 8:____________________________________
12.
Address of Above Institution (include street #, street, city, state/province, country & post
code):_________________________________________________________________________
______________________________________________________________________________
13.
List all jobs you have held during the past 3 years, starting with your current job at
LSU. Also list any other experience that qualifies you for the job opportunity.
Perm Information Questionnaire
Page | 1

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