Attestation for H-1C
U.S. Department of Labor
Nonimmigrant Nurses
Employment and Training Administration
ETA Form 9081
OMB Approval: 1205-0415
Expiration: 11/30/2010
I. Applicant's Information
(1) Full Legal Name of Applicant
(2) Federal Employer I.D. Number (9 digits) (EIN from IRS)
(3) Applicant's Telephone Number
(4) Return FAX Number
(5) Contact's Telephone Number (Optional - If contact is the hiring official leave blank.)
(6) Applicant's Address (Number / Street)
City
State
Postal Code
(7)
e initial on the second line.
Contact's Name (Optional - If contact is the hiring official leave blank.) Last name on the first line, first name & middl
(8) Correspondence Address (only use this area if correspondence should be sent to a location other than the Applicant)
(Number / Street/ Post Office Box or Rural Route)
dd
City
E-mail Address
State
Postal Code
@
II. Location of Facility
(1) County
City
State
Postal Code
(2) Census Tract (if known)
Complaints alleging misrepresentation of material facts in this Attestation and/or failure to comply with the terms of this Attestation may be filed with
any office of the Wage and Hour Division of the United States Department of Labor.
Employer's
Control
Number
Employer's Control Number must
Draft
Page - 1 of 3
be the same on all three (3)
pages, including the last page
Attestation for H-1C
U.S. Department of Labor
Nonimmigrant Nurses
Employment and Training Administration
ETA Form 9081
OMB Approval: 1205-0415
Expiration: 11/30/2010
ATTESTATIONS: See instructions and regulations ( 20 CFR Part 655, Subparts L & M)
Sections III through X on this form are the required attestations.
Place an X in the appropriate boxes below:
III. Eligibility
The hospital meets all of the following facility requirements: 1) it is a "subpart (d) hospital," 2) which was located in a health professional shortage
(1)
area on March 31, 1997, and 3) had at least 190 acute care beds with at least 35% of its acute care inpatient days reimbursed by Med