THE UNIVERSITY OF IOWA
FACULTY & STAFF IMMIGRATION SERVICES
University Services Building, 121-20 USB
CASE INITIATION FORM “PERM” LABOR CERTIFICATION
Form must be completed by the Employing Department (Not the Alien)
P&S Positions: Please attach in Word format to Workflow Requisition
Faculty Positions: Please e-mail to University of Iowa Faculty & Staff Immigration Services in Word format
Date:
Department Name:
Org#
Dept#
DEPARTMENT CONTACT INFORMATION
The department contact is the individual responsible for completing the Application Questionnaire and providing
appropriate supporting documentation (Not the Alien).
Department Contact Name:
Phone:
E-mail Address:
Fax#
Campus Address:
ALIEN INFORMATION
Name:
Job Classification:
Current Residing Address:
Campus Work Address:
Immediate Supervisor:
Current Immigration Status (if applicable):
Expiration Date:
Sponsoring Institution for Current Immigration Status (if applicable):
Is the Alien Currently in the United States?
Yes
No
By the submission of this document to the University of Iowa, Faculty and Staff Immigration Services through Workflow
and the electronic signature of the Department Representative on that Workflow transaction, you authorize Immigration
Services to initiate an employment-based petition for work authorization, as indicated above, on behalf of the abovenamed alien. You further agree to comply with the terms and conditions of the employer’s responsibilities related to the
alien’s employment at The University of Iowa.
*Because only the State Attorney General may represent The University of Iowa, retention of counsel by the Alien does not authorize
that attorney to serve as The University of Iowa’s agent for purpose of the preparation or filing of an employment-based petition of
the type listed above.
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Application Questionnaire to Obtain “PERM” Labor Certification Status for P&S
Form must be completed by the Employing Department (Not the Alien)
General and Biographical Information about the Alien Employee
Name:
Last (family name)
Gender:
male
First
Middle Name
female
Date of Birth:
Place of Birth:
City
State/Province
Country
Country of Citizenship:
Social Security Number (if applicable):
Foreign Address (Required for all employees):
Current Address (in the U.S.):
Phone Numbers (home):
(work):
E-mail Address:
Fax#:
Information about the Offered Position
1. Job title (attach position description)
2. State in detail the minimum education training, (e.g., example of postgraduate medical training), and experience for a
worker to perform satisfactorily the job duties (please quantify the duration of any minimum training or experience):
3. List any other special requirements e.g., special laboratory skills or techniques:
4. Name and occupational title of person who will be the employee’s immediate supervisor, including phone number:
5. Number of staff employee will supervise:
6. Salary for position (list salary you are/will be paying employee – do not list range):
7. Describe efforts to recruit U.S. workers and the results (specify sources of recruitment or proposed sources of
recruitment by name with dates):
8. List the criteria that were applied to final candidates who were interviewed for this position (e.g., quality of classroom
presentation, compatibility with current staff, promise as a researcher, etc.):
Employee’s Immigration History
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Not applicable if you have provided/submitted an H1B application/questionnaire to or office within the last 3 years
1. Current Nonimmigrant status:
2. Passport Issuance & Expiration Date:
3. Passport Country of Issuance:
4. Alien (A#) Registration Number (if applicable):
5. Date of Most Recent Arrival in the U.S. (if applicable):
6. I-94 Number and Expiration Date (if applicable):
7. Current Nonimmigrant Status expiration date (if applicable):
8. Provide information regarding employee’s previous stays in the U.S. (provide attachment if more space is required):
Classification
Validation Dates
Sponsoring Entity
9. Is employee subject to the section 212(e) two-year home residency requirement?
Yes
No
If yes, has the requirement been completed or waived? (Please provide details):
11. Has an I-140 immigrant petition (for permanent resident status) ever been filed on behalf of employee?
Yes
No
If yes, please provide details, including date petition approved, denied, or whether currently
pending and the petitioner?
12. Has employee ever been denied nonimmigrant (temporary employment based) immigration status in the U.S.?
Yes
No
If yes, please provide details:
Education History
List the names and addresses of Schools, Colleges and Universities that employee attended:
1) Name/Address (include city/country):
Field of Study:
Dates Attended (month/day/year to month/day/year):
Degree Received:
2) Name/Address (include city/country):
Field of Study:
Dates Attended (month/day/year to month/day/year):
Degree Received:
3) Name/Address (include city/country):
Field of Study:
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Dates Attended (month/day/year to month/day/year):
Degree Received:
4) Name/Address (include city/country):
Field of Study:
Dates Attended (month/day/year to month/day/year):
Degree Received:
5) Name/Address (include city/country):
Field of Study:
Dates Attended (month/day/year to month/day/year):
Degree Received:
Employment History
List all jobs (including any training positions) employee held during past (3) years or which qualify the employee
for the position. Please tab further if additional space is needed:
a) Name and Address of Employer:
Job Title:
Date Started (M/D/Y):
Date Left (M/D/Y):
Kind of Business:
Number of Hours per Week:
Name of Supervisor:
Telephone of Supervisor:
Describe in detail the duties performed, including the use of tools, machines, and/or equipment:
b) Name and Address of Employer:
Job Title:
Date Started (M/D/Y):
Date Left (M/D/Y):
Kind of Business:
Number of Hours per Week:
Name of Supervisor:
Telephone of Supervisor:
Describe in detail the duties performed, including the use of tools, machines, and/or equipment:
c) Name and Address of Employer:
Job Title:
Date Started (M/D/Y):
Date Left (M/D/Y):
Kind of Business:
Number of Hours per Week:
Name of Supervisor:
Telephone of Supervisor:
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Describe in detail the duties performed, including the use of tools, machines, and/or equipment:
d) Name and Address of Employer:
Job Title:
Date Started (M/D/Y):
Date Left (M/D/Y):
Kind of Business:
Number of Hours per Week:
Name of Supervisor:
Telephone of Supervisor:
Describe in detail the duties performed, including the use of tools, machines, and/or equipment:
P&S Positions: Please attach in Word format to Workflow Requisition
Faculty Positions: Please e-mail to University of Iowa Faculty & Staff Immigration Services in Word format
09/11/2006
jr/revised 10/22/2010
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