H-1B Nonimmigrant
U.S. Department of Labor
ESA Form WH-4
Information Form
Employment Standards Administration
OMB Approval: 1205-0310
Expiration Date: 11/30/2003
This report is authorized by 8 U.S.C. 1182(n)(2)(G)(ii) of the American Competitiveness and Workforce
Improvement Act (ACWIA) of 1998. The information provided on this form will assist the Department
of Labor in determining whether the named employer of H-1B nonimmigrants has committed a violation
of provisions of the H-1B program. Your identity will be kept confidential to the fullest extent provided
by law. 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 local Wage and Hour office of the U.S.
Department of Labor. After you submit the form, a representative from the Department of Labor may
contact you if further information is necessary to initiate an investigation.
1. Person Submitting Information (please print)
Mr., Miss, Mrs., Ms.
First Name
Middle Initial
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)
H-1B Nonimmigrant Employee
Former or
Current Employee (dates of employment):
(b)
U.S. Worker
Former or
Current Employee (dates of employment):
(c)
(d)
(e)
(f)
(g)
(h)
Job Applicant (date of application):
Competitor Business (please specify):
Federal Government Agency (please specify):
State or Local Government Agency (please specify):
Community or Service Organization (please specify):
Other (please specify):
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3.
Information on H-1B Employer Committing Alleged Violation
Name of Employer/Company:
Address:
Number, Street
City
State
ZIP Code
Employer Representative to be Contacted