PERM

EMPLOYEE (BENEFICIARY) Info Sheet

Are you seeking to utilize the filling date from a previously submitted application for alien employment
certification (ETA 750)?  YES  NO If “yes”, previous filling date: _____________________________
Previous Petitioner: _______________________________________ Case No.: _________________________

1. Last Name: _____________________________________________________

First Name: _____________________________________________________
Full Middle Name: _________________________________________________
2. Current US Address: No./St./Apt.: _____________________________________________________
City/State: ______________________________________________________________
Country: _______________________________________________________________
Postal Code: ____________________________________________________________
3. Phone number: ______________________________ Email Address: _____________________________
4. Country of Citizenship: ________________________________________________________
5. Date of Birth: _________________________ City/Country of Birth: _______________________________
6. Current Employer: ___________________________________________________________
7. Employer Address: ___________________________________________________________
8. Date employment commenced: ________________________________________________
9. Name and title of Supervisor: __________________________________________________
10. Job title and description: _________________________________________________________________
_____________________________________________________________________________________
11. Visa Class (status): ____________________________________________________
12. Alien registration number (A#): ____________________________________________________
13. Alien admission number (1-94): ____________________________________________________
14. Highest level of education achieved relevant to the required occupation: __________________________
15. Major field(s) of study: _______________________________________________ (attach diploma)
16. Date relevant education completed and degree conferred: __________________________________
17. Institution where relevant education specified in form ETA 9098, question 11, was received:
__________________________________________________________________________________
18. Address of conferring institution: ______________________________________________________
__________________________________________________________________________________