J

REPUBLICOF TITEMARSHALLISLAIVDS
IMMICRATION DIVISION. LABORDIYISION
Mqiuro,MarshollIslands
l*||***ttf *if il*t**t***t*tf t,t**t***ir**ilr

NOI.{RESIDENT WORKEP"S AFFIDAVIT

(Appllcrtlon
for LaborCcrtlflcotton
ondEntryPermJt for Employment)

hlnthSlbltlnlnkorutcrltpawrltcr. tlyounccdmor.rp.c.lofulltrnrrcrrnyqurrtlonronthlrforrn,utc.
t c P r r r l ct h ' c l ' l d c n t l f yc r c h r n r w c r w l l h t h c n u m b c ro f l h c c o r r c r p o n d t nq3u c s t l o n l ,
A m d o v t tm u d h r , r u b m l t r c It n
t orlxlnrt
rrtd four coplrr,

L l ' r m l l y n r m o I n c r p l r o ll c t t c r r Mlddh nrma Mrldcnnomc

Nrmc

2 , N u m h ( ,r n d S t r c c t Clty or Town Smt! rnd Zlp Codc Country ' 1 .M o r l l r l

Prc'ent
Addrcrr S l et u r
Il lr,lorrlcd
ll Slnglc

5, Nhn'r Bldhdotc 6, Elrthplrcc Cltyor Town Stricor Provln* Country

M o n i h ,D r y , Y c r r

7, Prortnt Nrtlonslltt or Cltlranthlp t, Plrpor'l No.

(Country)
Drt! lrrucd Plrcclrrucd

9, Nrmc& Addrc$of Employr,r

10. JobTltlc

ll.lundcrlrndthrtthirAffdrvlt|,|ubm|tt.drorGmp|oymcnton|/|nthrPot|tlon,tltcd||||tcmlorndonly*tththG.mp|oy!ri|tcd|ntlcmgrndrrh|l!und.l
c n p l o t c r , I r m p r o h l h l t t dh y h w l r o r n w o r U n gf o r o r b c l n 3c m p l o y c dh y r n y o t h r c m p l o y c or r t h ! R r p u b l l c
o f t h c M o r r i i r l l t r l r n d r G o v g n m c n r , d u r l n St h r t c r 1 1o f , ! c h
.on|||c|.|furthcrundGr3lrndlh|t|nkccP|n8wlththc|ntcn|ofth!RMtProtcct|onofRclidcntWorIcriActydu||c'
d l r c t c db y m y c m p l o y c r .

1 2 ,N r m * & A d d r c m
of &hoolr,CollrScr
& U n l v c r r l t l i lA t r c n d c d .
l n c l u d cT m d c o r V o c r t l o n o l
Dcgrccror Ccrllf'lcrtct
Tnlnlnt Frcllltlcr. p6q(|rn

SPECIA.L
OUALrnrCAT!pNg.AN.p
SKTLLS

lJ, Addltlorrrlquolltl{rtlont rnd rktlh Allcn poluru rnd prollclcncyln thr ut ol toolr, hrchlnrr ot tqulpmcntwhlchwould
h ( l p c r t r h l l r h rl f A l l c n m f c t , r e q i l l r c m c n tlio r o c c u D r t l oInn l t c m l 0

l,l, LlJt lJccnr(r (ltrofc*slonrl,Journctntrnr ctc.)

1 5 ,L l l t d o c u m c n trrt t u c h c dw h l c hr r t t u b m l t t c dr r c v l d c n c tsh o t N l c n ' i n r r $ r c r t h ! E d u c r t l o nT, l r l n l n g , G x p * l c n c r n d r b l l l t l r r

rcprclcntcd,

1 6 ,L l t t r l l J o b l h s l d w h l N hr 0 l 0 l r l o v o r k c r p c r l c n c lan t h c o r c u p r t l o nI n d l c r t c dl n l t c m 1 0 , A m l n l m u mo f t w o ( 2 ) t . e r r
w o r kc r p r r l { n c cl n t h ( t p ( r l n c o c c u p o t l obn r c q u l r c db y l r w ,

Nrmt & Addf$r of l)mploytr

Tltlr of Job

D r i c r l h c I n d c l r l l t h c d u t l c l p c r f o f m c d , I n c l u d l n gt h c u r c o l t o o l i , M r c h l n l t o r & l u l p m t n t ,

I t c m rc o n t l n u c o
dn r r v c r r c
Nmc & Addrgr of &nployct

D*cribcin dcuil0rcduticspcrformcd, thcuscof looir,Mrchinqol E4ulpmcnt,

including No,of HourrPctWccl

Nlmo& Addr*r of f,tnploYcr

Dc*ribciu dc||ilthcduricrpcrformod, oc u3cof toolr,Mrohlndor F4uipmcnt,

including No,of HourtPcrWccl

(Spourc,Chlldton'ctc.)
I 7, Lllt ol dopcndcnF

Narne I Detcof Binh

ri chrngc,occutby nlinS
plcgc ootc: lt ir thc rcrponribilityol thc non.rqidcntworlcr to lr.ncndtlrir llrt of dcpendcnF
l lcttcrol lrncrtdnrcntwitlr thc F.tnphrymcntrcrvlccOfficc.

1 8 .P o l i c cR c c o t d

| 9. H*llh Ccrtificltion

rorr phyricrl
iorHorpirrr)
rcrviccr
riilriry'[rHc'rrh cx.m]glio! , - ^ a . n . rrtct
wllinrcn dovr r'v lInto
^ t t - ' . "cntrv n r n rthc RMt'
he Q MI
ilr'i:;['ii:;ffi:;#j; ffi;;'il;'irii.

rMMt0RATIONINFOR\4ATlON

20,Hlvcyoucvsrrpplic.d of thcMrnlrlll lslrndrcntrypcrmitbcforc?

for Rcpublic
lf ter. whcn& fot wllll purpotc: Ycr- Wruthcenlrypcrmitl Grrntcd?- Dcnicd?- Rcvokcd?
No-
Grunrud rvlutls rhcentrypcrrnir
No: Drtcof cxpirltion:
- labor.lD'No:
(if rppllclblc)

ppcLARATION
ticrclo
supplcmcnB
this0Pplication.
DECL,\RA]]ON OF NONRESIDENT WORKER; undcrpcnrlricilrpcrjury,I dcehrcr,ut I hovccrrmincd
rnd
documgnur to ho b$t of rny ro$,
knowlcrjgc boliof,rlroInlormllion hcrconir lruc,coftcct'lnd
prg3cntcd
Utdi.rf0lnlrnying
':;
oonu,l(tt,

illl(l t\|ilrll trr bskrrcIng' I notaryPublisin rnd fot ths

Suhsdrrhlt(l

ilris*;diy ol'J:*_-- 19

crpircton
My cornmission