Fillable Jackson State University H-1 B Form 1 : (Jackson State University)

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Jackson State University H-1 B Form 1 : (Jackson State University)

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H-1 B Application2/1/2011
1
• Jackson State University •
• H-1 B –Form 1 : Request For Information From the Department •
Division of International Studies • Jackson State University • Office Complex Unit 1, Box 17103 • Jackson, MS 39217 • USA
Phone: (601) 979-3796 • Fax: (601) 979-3388
E-mail: patricia.a.jernigan@jsums.edu
Please submit the following information. Be sure to type or print clearly.
It is very important that you read the following carefully and not sign anything unless you are in total agreement.
REQUIRED WAGE DETERMINATION WORKSHEET AND COMPLIANCE AGREEMENT
REGARDING H-1B TEMPORARY WORKERS
PART 1: POSITION DESCRIPTION – TO BE COMPLETED BY DEPARTMENT CHAIR
PLEASE ENTER INFORMATION ABOUT POSITION REQUIREMENTS, NOT PROSPECTIVE EMPLOYEE’S QUALIFICATIONS
Hiring Department/ Unit: ________________________________________________________________________________________
School/ Division: ______________________________________________________________________________________________
Position Title : ________________________________________________________________________________________________
Position’s minimum degree requirement: ___________________________ Field(s) of study: _________________________________
Position’s minimum required training and experience (other than that which would or could have been obtained during the normal course of
the degree program listed above) Please quantify required training and experience in number of years:
_______________________________________________________________________________________________________________
_______________________________________________________________________________________________________________
_______________________________________________________________________________________________________________
Description of basic job duties:
_______________________________________________________________________________________________________________
_______________________________________________________________________________________________________________
_______________________________________________________________________________________________________________
Proposed Salary: ________________________________________
Hours/ Range of hours per week: Per year or Per nine months
There are no additions or deductions from each pay period, nor overtime. (Check if true)
Benefits: (Check all that apply)
Position includes NO additional compensation or benefits
Position includes standard Jackson State University employee benefits
Position includes additional compensation (specify) ______________________________________________________________________________
with an estimated dollar value of (per year): _____________________________
Has this Department received TARP Funding? Yes____ No____
Number of employees applicant will supervise (other than students): ______________________________
Dates of intended employment (Total H-1B limit is 6 years – 3 years allowed per petition): From ______________ To ______________
Work location address: ____________________________________________________________________________________________
Occupational title of person who will be employee’s immediate supervisor: ___________________________________________________
H-1 B Application2/1/2011
2
• Jackson State University •
• H-1 B –Form 1: Request For Information From the Department •
PART 2: ACTUAL WAGE DETERMINATION – TO BE COMPLETED BY DEPARTMENT CHAIR
Prospective H-1B employee name: ________________________ : ____________________________ : ___________________________
Family Name (Last) Given Name (First) Middle Name (if any)
U.S. Social Security # (if any): _______________________________________
For “actual wages,” the Department of Labor refers to the range of wages paid to all workers similarly employed, i.e., those with the same
job title and basic job duties for which educational requirements are the same. Please list below the Employee’s J-Number or Social
Security Number and actual wages of ALL workers similarly employed in your department. Explain ANY
salary differences by
describing factors such as experience, unique skills or abilities, quality of the program from which an employee graduated,
extraordinary or meritorious contributions, or other variables resulting in a higher salary being paid when applicable.
Salary data as of (Month/Day/Year): __________________________________________
J Number or Social
Security Number
Current
Salary
Basis (9 mo/ yr)
When salary differs from prospective employee’s, please explain why
1. $
2. $
3. $
4. $
5. $
Presently, the department has no one filling a position comparable to the proposed H-1B.
(Note: If there is no comparable position to the proposed H-1B, the position may have to be compared to others on a school-wide or
division-wide basis. If no comparable position exists within the school or division, the dean’s office or equivalent must verify this.)
PART 3: PROSPECTIVE EMPLOYEE CONTACT INFORMATION
Current Mailing Address : _____________________________________________________________________________________________________
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
E-mail address: ______________________________________________________________________________________________________________
Phone Number (with country and city code): _______________________________________________________________________________________
Fax Number (with country and city code): ________________________________________________________________________________________
H-1 B Application2/1/2011
3
• Jackson State University •
• H-1 B –Form 1: Request For Information From the Department •
PART 4: LEGALLY BINDING EMPLOYER ATTESTATIONS
From US Immigration Service [8 CFR 214.2 (h)] & US Department of Labor [20 CFR Parts 655 and 656]
By signing below, I attest that the above information is true and that the Jackson State University will comply with the following
statements as required by the Immigration Act of 1990 and conforming regulations issued by the US Department of Homeland
Security and Department of Labor.
1) That the H-1B worker will be paid the actual or prevailing wage, whichever is higher (Actual wage is weighted average of salaries
listed above; prevailing wage is set by Department of Labor);
2) That the H-1B worker will also be paid for non-productive time unless contract is for a specified time period common to the industry
such as 9 month academic appointments;
3) That the H-1B worker will be offered benefits on the same basis as similarly employed US workers;
4) That the employment of H-1B workers will not adversely affect the working conditions of workers similarly employed in the area of
intended employment;
5) That on the date this form is signed and submitted, there is no strike, lockout or work stoppage in the course of a labor dispute in the
occupation in which the H-1B worker will be employed at the place of employment;
6) That notice of the H-1B application will be provided to workers employed in the occupation in which the H-1B will be employed as
signified by posting the Labor Condition Application in two conspicuous places (The Division of International Studies will provide
department with the Labor Certification Application along with posting and removal instructions);
7) That the reasonable cost of return transportation to the H-1B’s home country will be covered by the employer in the event employment
is terminated prior to the ending date on the H-1B petition submitted to US Citizenship and Immigration Services. (See dates entered
in part 1)
Required Signatures:
Department Chair:
Date: __________________________________________
Dean:
Date: __________________________________________
LEGAL NOTES AND COMPLIANCE
Any misrepresentation of facts or employer’s failure to comply may result in the following (affecting the entire Jackson State
University not just the department):
• Assessment of back pay for the foreign national and/or other employees in the occupational classification
• Maximum of $1000 fine for each violation
• Imposition of other appropriate administrative remedies
• A suspension of the employer’s labor condition applications and a prohibition of filing and approval of labor condition applications or applications for
permanent alien employment certification for one year
• A prohibition of the filing of immigrant or nonimmigrant visa petitions with US Immigration and Citizenship Services for at least one year
• Federal criminal penalties for knowing and willful submission of false statements to the Federal Government of $10,000 and/or imprisonment of up to
5 years
After completion of parts 1, 2, 3, and 4, return Form 1 and
the department support letter to:
Division of International Studies
Office Complex Unit 1, P.O. Box 17103
Jackson, MS 39217
H-1 B Application2/1/2011
4
SAMPLE LETTER FROM DEPARTMENT/ PETITIONER
(JACKSON STATE UNIVERSITY LETTERHEAD)
(DATE)
U.S. Citizenship and Immigration Services
California Service Center
ATTN: CAP EXEMPT H-1B Processing Unit
P.O. Box 10129
Laguna Niguel, CA 92607 -1012
Re: I-129 (H-1B) Petition on behalf of ______________
Dear Sir or Madam:
We are writing this letter in support of our petition to classify _________________ as an H-
1B nonim migrant, so that we may employ him in the specialty oc cupation of
_______________________. To this end we describe below the nature of our business
operations, the proposed employment, and __________ professional qualifications.
THE PETITIONER
Jackson State University has a distinguished history, rich in the tradi tion of educating young
men and women for leadership, having undergone seven name changes as it grew and developed.
Founded as Natchez Seminary in 1877 by the American Baptist Home mission Society, the school
was established as Natchez, Mi ssissippi "for the mo ral, religious and intellectual improvement of
Christian leaders of the colored people of Missi ssippi and the neighboring st ates." In November
1882, the school was moved to Jackson; in Marc h 1899, the c urriculum was expanded and the
name was changed to Jackson College.
The state assumed support of the college in 1940. Subsequently, between 1953 and 1956,
the curriculum was expanded to include a graduate pr ogram and bachelor's programs in the arts
and sciences; the name was then changed to Jackson State College in 1956. Further expansion of
the curriculum and a notable buildin g program preceded the elev ation of Jackson Stat e College to
university status on March 15,1974. In 1979, Jackson State was officially designated the Urban
University of the State of Mississippi.
Presently, Jackson State Univer sity, a public, coeduc ational institution, is supported by legislativ e
appropriations supplemented by st udent fees and f ederal and priv ate grants. The University
employees around 1593 employees and is still growing.
H-1 B Application2/1/2011
5
THE POSITION OFFERED
At this time we wish to employ ________ in the position of _______________. In this
position _____________ will be responsible for (detailed description of duties)
THE BENEFICIARY’S QUALIFICATIONS
__________________ is hi ghly qualified to undertake this employment, based on his
relevant education and professional experiences (fully describe applican t’s educational and
professional experience).
TERMS OF EMPLOYMENT
For his professional services, _____________ will receive a base salary of ________ _____
per year. This com pensation is meet the prevailing wage for similar positions and will not
adversely affect the working c ondition of similarly employed U. S. workers. Further, if
_____________ were to be dismissed by Jackson State Un iversity prior to the expiration of his H-
1B status, we will compensate him for the reasonable cost of his return transportation to his home
country. We further understand that ____________ voluntary termination of his employment would
no be considered as a dismissal.
Based on the foregoing, we submit that _________ _____ is eligible for H-1B class ification
and we respectfully request a favorable decision on our petition.
Thank you for your consideration.
Respectfully,
H-1 B Application2/1/2011
6
Jackson State University
Request for Payment
To: Financial Services
From:
e-mail
Date:
Payment to: DEPARTMENT OF HOMELAND SECURITY
USCIS – CA
LIFORNIA SERVICE CENTER
ATTN: CAP
E
XEMPT H-1B PROCESSING UNIT
P.O. Bo
x
10129
Laguna, Niguel, CA 92607-1012
Item
Amount
Purpose:
Payment of fees for the
H1B Petition for:
ATTENTION: PATRICIA JERNIGAN (601-979-3796)
Information to be include
d on check
stub:
Reference:
(Internation
al Employee’s Name)
Text:
NOTE: File
separate requests for each filing fee so that separate checks will be processed.
H-1 B Application2/1/2011
7
Interoffice Memorandum
DIVISION OF INTERNATIONAL STUDIES
Division of International Studies
Office Complex Unit 1, P.O. Box 17103
Jackson, MS 39217
601-979-3796
TO: Financial Services
FROM: Patricia Jernigan, Assistant Dean
Division of International Studies
DATE:
SU
BJECT: H-1B Filing Fees For (Name of Applicant)
When filing for H-1B status on behalf of a university employee or intended employee, the Jackson State
University may pay the Department of Homeland Security, US Citizenship and Immigration Services the
Fraud filing fee and may pay the other fee(s) for the related paperwork (USCIS form I-129). If not, the fees
will be the responsibility of the beneficiary.
There are four possible filing fees associated with an H-1B Petition. As of November 23, 2010, the filing
fees are as follows:
1. Standard filing fee for the I-129 (necessary for all H-1B Petitions) - $325
2. Anti-fraud fee (for all new H-1B Petitions with JSU) - $500
3. Premium Processing fee (for expedited processing) - $1225.00
4. Division of International Studies processing fee - $500.00
The following guidelines are given by the USCIS for payment preparation:
- All filing fees must be paid with separate checks or money orders.
- The check(s) or money order(s) must be drawn on a bank or other financial institution located in the United
States and must be payable in U.S. currency. Do not mail cash.
- Make the check(s) or money order(s) payable to:
D
EPARTMENT OF HOMELAND SECURITY
USCIS – CALIFORNIA SERVICE CENTER
ATTN: CAP EXEMPT H-1B PROCESSING UNIT
P.O. Box 10129
LAGUNA NIGUEL, CA 92607-1012
When the check or money order is ready, it should be returned to the Division of International Studies, NOT
the USCIS. A check sent directly to the USCIS will be returned and will cause delays in the application
process.
H-1 B Application2/1/2011
8
• Jackson State University
•
H-1 B – Form 2: Request For Information From The Applicant •
Division of International Studies • Jackson State University • Office Complex Unit 1, Box 17103 • Jackson, MS 39217 • USA
Phone: (601) 979-3796 • Fax: (601) 979-3388
E-mail: patricia.a.jernigan@jsums.edu
Please submit all of the following information, even for H-1B extensions:
Be sure to type or print clearly
DO NOT STAPLE ANY DOCUMENTS TOGETHER
H-1B APPLICANT DEMOGRAPHIC INFORMATION
NAME AND RESIDENCE INFORMATION:
Full Name (as it appears in your passport): _______________________________ : ____________________________ : __________________________
Family Name (Surname) Given Name (First) Middle Name (if any)
All other names used : _________________________________________________________________________________________________________
(Include maiden name and names from all previous marriages
Place of Birth (required): __________________________ : _________________________________________ : _______________________________
City Province/ State Country
Residence Information (required): _________________________________________ : ____________________________________________________
Country of Citizenship Country of Permanent Residence
Date of Birth (Month/ Day/ Year): _______________________________________ Gender : ___________________________________________
CONTACT INFORMATION:
Residential Address Outside of the U.S. : _________________________________________________________________________________________
__________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________
E-mail address: _____________________________________________ Fax Number: _____________________________________________________
JACKSON STATE UNIVERSITY POSITION INFORMATION:
(Please provide contact information for your intended employer at the Jackson State University)
JSU Academic Department: _________________________________________ Supervisor’s Name: ________________________________________
US VISA HISTORY INFORMATION:
Have you ever been in the United States in any non-immigrant status? YES or NO.
If YES, please list all time in the US in non-immigrant visa status. If more space is needed, please attach a separate page for your visa history:
1. Immigration Status (i.e. F-1, J-1, H-4): ____________ Dates of Stay (Month/ Day/ Year): ___________________ through ___________________
2. Immigration Status (i.e. F-1, J-1, H-4): ____________ Dates of Stay (Month/ Day/ Year): ___________________ through ___________________
3. Immigration Status (i.e. F-1, J-1, H-4): ____________ Dates of Stay (Month/ Day/ Year): ___________________ through ___________________
Have you ever been in the United States on a J Visa (J-1 or J-2)? YES or NO.
Are you subject to the 212(e), Two-Year Home Residency Requirement (only possible if currently or previously on J-Visa)? YES or NO.
If subject to 212(e), what is your current status? (Please Check One) Applied for waiver
Received waiver (Please Include Proof of Waiver)
Completed requirement in home country
None of the above
Have you ever been denied an H-1B? YES or NO.
Do you have any pending immigrant petitions (Permanent Residency Application)? YES or NO.
H-1 B Application2/1/2011
9
Jackson State University
• H-1 B – Form 2: Request For Information From The Applicant •
IMMIGRATION INFORMATION
Passport # : _________________________________________________ Passport Country: _______________________________________________
Passport Issue Date (Month/ Day/ Year): __________________________ Passport Expiry Date (Month/ Day/ Year): ____________________________
[Please note that passports must be renewed at least 6 months prior to their expiration date.]
U.S. Social Security Number (If any): __________________________________
A # (If any. Alien number is listed on EAD Cards, OPT Cards, and on any I-140 or I-485 Notices) : __________________________________________
At which consulate will you apply for your H-1B Visa stamp? City (outside of the U.S.): __________________ Country: ______________________
FOR APPLICANTS CURRENTLY IN THE UNITED STATES ONLY
Current Non-Immigrant Visa Status (i.e. F-1, J-1, H-1B) : _________________________________________________
Date of Last Arrival (stamped on I-94 Card) (Month/ Day/ Year): __________________________________________________________
Date Current Visa Status Expires (Month/ Day/ Year): ___________________________________________________________________
I-94 # (Eleven Digit Number White Card in Passport): _______________________________________
Are you currently on F-1 Optional Practical Training (OPT)? YES or NO.
If YES, List dates of OPT: (Month/ Day/ Year): __________________________ through (Month/ Day/ Year): __________________________
Do you have any dependents (spouse or children) who will file for H-4 status with this petition? YES or NO. If yes, how many?: ___________
Residential Address in the U.S. : ______________________________________________________________________________________________
________________________________________________________________________________________________________________________
Phone Number: _____________________________________________ Fax Number: ____________________________________________________
REQUIRED DOCUMENTATION TO BE SUBMITTED TO THE DIVISION OF INTERNATIONAL STUDIES
**DO NOT STAPLE ANY DOCUMENTS TOGETHER**
One support letter from the department attesting to the quality of applicant’s work (sample letter attached)
Curriculum Vita/ Resume which includes current address, home country address, statement of work history, and list of publications
Copy of all university-level academic degrees, diplomas, and transcripts/mark sheets.
- Diplomas and transcripts/mark sheets do not have to be originals
- On the back of each photocopy, sign a statement that says “This is a true photocopy and originals are available upon request.”
- Documents not in English will be translated by the Division of International Studies
- Degrees or documents issued by non-U.S. institutions will have to have a foreign credential evaluation processed by International Programs
Copies of 3 most recent pay stubs/ paycheck notifications if currently employed in the US
Copy of Passport Identification Pages (Full-page photocopies ONLY. Do not cut the photocopy to the shape of the passport) **
Copies of current/ most recent Visa Stamp **
Copies of I-94 Card (FRONT AND BACK) **
Copies of all previous I-20’s, DS-2019’s, IAP-66’s, and H-1B or H-4 I-797 Approval Notices**
Copy of Employment Authorization Card (i.e. F-1 OPT Card or J-2 EAD Card) if currently working on Employment Authorization
Proof of I-612 waiver or completion of 212(e) Two-Year Home Residency Requirement if currently or previously on J-Visa**
H-4 Application: If you have dependent family members who are already in the U.S. in H-4 status on another visa type, and you would like to
change/extend their status as an H-4 dependent, include the following:
- Form I-539 (available on www.uscis.gov
site) and check for $300 made payable to Department of Homeland Security
- Include the above starred (**) items for your family members
- Birth Certificate and Marriage Certificate
H-1 B Application2/1/2011
10
Jackson State University
• H-1 B – Portability Attestation •
(Only for H-1B Transfers from other employers)
To Whom It May Concern:
I understand that under the U.S. Immigration and Naturalization Act as amended by the American Competitiveness
for the 21
st
Century Act of 2000, [AC21 § 105], [INA § 214 (a) (m)], non-immigrants currently in H-1B status with
one employer can begin employment with a new employer as soon as the new employer files the I-129, H-1B
petition for new H-1B employment. The new employer and H-1B applicant do not have to wait for the new petition
to be approved in order to begin employment. I understand that I am eligible to begin working at the Jackson State
University (JSU) provided:
1) I have been previously issued an H-1B visa or otherwise provided H-1B non-immigrant status;
2) I have been lawfully admitted into the United States as a non-immigrant;
3) I have not engaged in employment without authorization since that admission;
4) I am currently the beneficiary of a I-129 petition for new H-1B employment which has been filed with the
Department of Homeland Security – US Citizenship and Immigration Services before the expiration of my
current period of authorized stay
5) I recognize that if the new H petition is denied, my “portability” work authorization is automatically terminated.
By signature below, I certify that I have read and understood the conditions set forth in INA § 214 (a)(m), and that I
qualify for the “portability” benefit based on my current H-status and the fact that an application for my
employment at the Jackson State University has been timely filed and a USCIS receipt notice for the filing has been
received by the Division of International Studies. I also recognize that if the petition to transfer my H-status to the
Jackson State University is denied that my “portability” work authorization is automatically terminated.
SIGNATURE: __________________________________________
PRINTED NAME: __________________________________________
DATE: __________________________________________
Return Portability Attestation to:
Division of International Studies
Jackson State University
Office Complex Unit 1, Box 17103
Jackson, Mississippi 39217
601-979-3796
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Jackson State University H-1 B Form 1 : (Jackson State University)

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Completed 23 July 2020

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