Form Wh-4 - Nonimmigrant Worker Information Form
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1
2
3Nonimmigrant Worker
U.S. Department Of Labor
Information Form
Employment Standards Administration
Wage and Hour Division
.
OMB Control No.: 1205-0310
Expiration Date: 01/31/2012
.
This report is authorized by the American Competitiveness and Workforce Improvement Act (ACWIA) of 1998. 8 U.S.C.
§§ 1182(n)(2)(G), 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. Your identity will be kept confidential to the fullest extent provided by law. 5 U.S.C. § 552(b)(7)(D). Please
provide as much of the requested information as possible. Attach additional sheets if you need additional space to respond to a question.
If you do not understand a term, or need assistance in the completion of this form, please contact the Wage and Hour Division of the
U.S. Department of Labor: 1-866-4USWAGE (1-866-487-9243). After you submit the form, a representative from the DOL may
c
ontact you if further information is necessary to initiate an investigation.
1.
Person Submitting Information (please print)
Mr., Miss, Mrs., Ms.: ______________________________________________________________________________________________
First Name
Middle Name
Last Name
Current Address:
______________________________________________________________________________________________
Number, Street, Apt., or P.O. Box No.
______________________________________________________________________________________________
City,
State,
ZIP Code
Telephone Number (including area code): _____________________________________________________________________________
Days/Times When You Can Be Reached at that Number: _________________________________________________________________
E-Mail Address (optional): _________________________________________________________________________________________
_____________________________________________________________________________________________________________________
2.
Nature of Source’s Relationship to Employer (Please check all that apply)
(a)
Nonimmigrant Worker
H-1B
H-1B1
E-3
Former or
Current Employee (dates of employment): __________________________________
(b)
U.S. Worker
Former
Current Employee (dates of employment): __________________________________
(c)
Job Applicant (date of application):
___________________________________________________________________
(d)
Competitor Business (please specify): ___________________________________________________________________
(e)
Federal Government Agency (please specify):
____________________________________________________________
(f)
State or Local Government Agency (please specify): _______________________________________________________
(g)
Community or Service Organization (please specify): _______________________________________________________
(h)
Other (please specify): _______________________________________________________________________________
___________________________________________________________________________
Continued on Next Page
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Form WH-4
Rev. October 2008
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