Fragomen, Del Rey, Bernsen & Loewy

Fragomen, Del Rey, Bernsen & Loewy

Cummins

PERM Labor Certification Questionnaire - Employee

For completion by employee

Please note: Failure to complete all sections may result in substantial delay in the processing of this case. We may require additional information following review.If a question does not apply, please put "none" or "not applicable" (N/A).

Important Warning: In general, a PERM application is valid only for the specific position and location described in the application. A change in job duties, job location, or position subsequent to commencement of the PERM process may render the PERM application unusable. Please immediately inform CBS and Fragomen of any potential change in your job duties, job location, or position.

BIOGRAPHIC INFORMATION

Name of employee (as it appears in passport):
Last Name:
First Name:
Middle Name:
Maiden Name or Alias:
Gender: / Female Male
U.S. Social Security Number:
U.S. Alien Registration Number (“A #”): (if applicable)
Home Address in USA
Street Address:
City:
State:
Zip Code:
E-mail Address:
Daytime Telephone Number:
Daytime Fax Number:
Home Telephone Number:
Cellular Number:
If you are planning to move in the next few months, please advise us of your anticipated moving date and your new address, if known:

Foreign Address

Street Address:

City:

State/Province:

Zip Code:

Country:

Personal Data

Date of Birth (mm/dd/yyyy):
City of Birth:
Country of Birth:
Country of Citizenship:
If dual citizen, please provide Country of Citizenship:
Current Immigration Status:
If in the U.S., Form I-94#:
Date and place of last arrival:
Expiration of status as shown on Form I-94 card or Form I-688: (mm/dd/yyyy)
Have you or your accompanying family members ever applied for
U.S. permanent residence (i.e. green card, I-140, I-130)? / Yes No
If yes, please specify date and place of filing, and result:
Have you or any accompanying family members ever been arrested, cited, charged, indicted, fined or imprisoned for breaking or violating any laws or any ordinances, excluding traffic violations? / Yes No
If yes, please explain:
Are you engaged, or do you have plans to marry a U.S. citizen or permanent resident? If yes, please provide details.
List all Educational Institutions attended: (If more space is required please submit attachment)
1. Full University Name:
University Location (street address/city/state/country/postal code):
Date Attended From (mm/dd/yyyy):
Date Attended To (mm/dd/yyyy):
Major/field of study:
Degree received, if any (e.g., B.S., M.S., Ph.D., etc.)
2. Full University Name:
University Location (street address/city/state/country/postal code):
Date Attended From (mm/dd/yyyy):
Date Attended To (mm/dd/yyyy):
Major/field of study:
Degree received, if any (e.g., B.S., M.S., Ph.D., etc.)
3. Full University Name:
University Location (street address/city/state/country/postal code):
Date Attended From (mm/dd/yyyy):
Date Attended To (mm/dd/yyyy):
Major/field of study:
Degree received, if any (e.g., B.S., M.S., Ph.D., etc.)
If applicable, please list any certifications and/or licenses and the year obtained:
Current Employment:
Name of Employer:
Street Address:
City:
State:
Zip Code:
Current job title:
Current annual salary:
Detailed description of your current duties.
Dates of Employment (mm/dd/yyyy)
(please indicate exact dates): / FromTo
Please indicate all techniques, methodologies, or other skills used:
Name of immediate supervisor/manager:
Supervisor’s title:
Supervisor’s telephone number:
Do you have an ownership interest, or a familial relationship with the owners, stockholders, partners, corporate officers, or incorporators of Cummins?
If “yes”, please provide details. /

Y/N

Did Cummins pay for any of your education or training necessary to satisfy any of the job requirements of the position you are being sponsored for? / Y/N
Employment History: Please list by employer and not by project
(If more space is required please submit attachment)
Name of employer:
Dates of employment (mm/dd/yyyy)
(please indicate exact dates): / FromTo
Street Address:
City:
State:
Country:
Postal/Zip Code:
Employer Phone Number:
Supervisor’s Name:
Type of Business:
Hours worked per week:
Was the position part time?
Job title:
Detailed description of duties.
Name of employer:
Dates of employment (mm/dd/yyyy)
(please indicate exact dates): / FromTo
Street Address:
City:
State:
Country:
Postal/Zip Code:
Employer Phone Number:
Supervisor’s Name:
Type of Business:
Hours worked per week:
Was the position part time?
Job title:
Detailed description of duties.
Name of employer:
Dates of employment (mm/dd/yyyy)
(please indicate exact dates): / FromTo
Street Address:
City:
State:
Country:
Postal/Zip Code:
Employer Phone Number:
Supervisor’s Name:
Type of Business:
Hours worked per week:
Was the position part time?
Job title:
Detailed description of duties.
Name of employer:
Dates of employment (mm/dd/yyyy)
(please indicate exact dates): / FromTo
Street Address:
City:
State:
Country:
Postal/Zip Code:
Employer Phone Number:
Supervisor’s Name:
Type of Business:
Hours worked per week:
Was the position part time?
Job title:
Detailed description of duties.
II. SUPPORTING DOCUMENTATION
Please provide the following documentation, if you have not previously sent them to us:
EDUCATIONAL DOCUMENTS
Copies of all university-level and post graduate educational documents (diplomas, transcripts, course lists, etc.)
CORPORATE JOB DESCRIPTION
Provide corporate job description, if applicable.
PASSPORTS
Complete copy of current passports (including blank pages) as well as expired passports containing U.S. visa(s)
I-94 (ARRIVAL AND DEPARTURE RECORD)
If in the U.S., current copies of Forms I-94 (front and back), making sure that the admission date-stamp is legible on all copies.
FORMS I-797, I-20, EADs, and other immigration documents
Copy of current and prior I-797s, nonimmigrant petition approval(s), Form I-20 student certificate, DS-2019 exchange visitor form, Employment Authorization Document (EAD)

Please note that you will also be required to provide letters from prior employers and/or educational institutions to verify that you have whatever work experience or special requirements that may apply to the position you are being sponsored for. Please do not request these letters yet. Your Fragomen caseworker will provide assistance and guidance regarding the necessary content of the appropriate letter(s).

By submitting this questionnaire I am confirming that all of the facts provided are accurate. I understand that civil and criminal penalties exist for individuals who knowingly provide false information to be used in U.S. government applications.

______

SignatureDate

* Affiliated through Fragomen Global Immigration Services, LLC

Fragomen, Del Rey, Bernsen & Loewy

The manager and the employee should complete this chart together. The manager should list the required special skills for the position and the particular job duty to which the skill corresponds (Columns 1 and 2). The employee should list where the skill was acquired and how it will be documented (Columns 3 and 4). In completing this chart, please note the following:

The listed skills must be part of the minimum requirements for the position.

The employee must have attained the listed skills before he/she began in the position covered by the PERM application.

Each skill listed must be objective (not a “soft” skill). Do not use terms that are subjective or difficult to quantify (e.g., experience managing “large” budgets).

The required skills must be available outside Cummins. They cannot be Cummins-specific.
Do not list skills that are duplicative of other required skills.

Please complete and return this chart. The employee will be required to obtain employment verification letters, transcripts, and/or academic verification letters based on the information provided below. Do NOT request letters at this time. Your Fragomen caseworker will provide assistance and guidance regarding the form and content of the appropriate letter(s).

Special Skill Requirement /

Job Duty to Which the Skill Corresponds

/ Where the employee gained this experience / Documentation employee will provide to prove skill (e.g.: employment letter, transcript)

To Be Completed By the Employee:

By submitting this document, I am confirming that all of the facts provided are accurate. I understand that civil and criminal penalties exist for individuals who knowingly provide false information to be used in U.S. government applications.

Signature: ______Date: ______

* Affiliated through Fragomen Global Immigration Services, LLC