| CASE NUMBER | I-200-24268-359441 |
| CASE STATUS | Certified |
| RECEIVED DATE | 9/24/2024 |
| DECISION DATE | 10/1/2024 |
| ORIGINAL CERT DATE | |
| VISA CLASS | H-1B |
| JOB TITLE | Senior Field Test Engineer |
| SOC CODE | 17-2112.00 |
| SOC TITLE | Industrial Engineers |
| FULL TIME POSITION | Y |
| BEGIN DATE | 10/21/2024 |
| END DATE | 10/20/2027 |
| TOTAL WORKER POSITIONS | 1 |
| NEW EMPLOYMENT | 0 |
| CONTINUED EMPLOYMENT | 0 |
| CHANGE PREVIOUS EMPLOYMENT | 0 |
| NEW CONCURRENT EMPLOYMENT | 0 |
| CHANGE EMPLOYER | 1 |
| AMENDED PETITION | 0 |
| EMPLOYER NAME | Form Energy, Inc. |
| TRADE NAME DBA | |
| EMPLOYER ADDRESS1 | 30 Dane Street |
| EMPLOYER ADDRESS2 | |
| EMPLOYER CITY | Somerville |
| EMPLOYER STATE | MA |
| EMPLOYER POSTAL CODE | 2143 |
| EMPLOYER COUNTRY | UNITED STATES OF AMERICA |
| EMPLOYER PROVINCE | |
| EMPLOYER PHONE | 15084313479 |
| EMPLOYER PHONE EXT | |
| NAICS CODE | 335999 |
| EMPLOYER POC LAST NAME | Urbanski |
| EMPLOYER POC FIRST NAME | Marlayna |
| EMPLOYER POC MIDDLE NAME | |
| EMPLOYER POC JOB TITLE | Senior People Systems Specialist |
| EMPLOYER POC ADDRESS1 | 30 Dane Street |
| EMPLOYER POC ADDRESS2 | |
| EMPLOYER POC CITY | Somerville |
| EMPLOYER POC STATE | MA |
| EMPLOYER POC POSTAL CODE | 2143 |
| EMPLOYER POC COUNTRY | UNITED STATES OF AMERICA |
| EMPLOYER POC PROVINCE | |
| EMPLOYER POC PHONE | 15084313479 |
| EMPLOYER POC PHONE EXT | |
| EMPLOYER POC EMAIL | murbanski@formenergy.com |
| AGENT REPRESENTING EMPLOYER | Yes |
| AGENT ATTORNEY LAST NAME | Bahar |
| AGENT ATTORNEY FIRST NAME | Arash |
| AGENT ATTORNEY MIDDLE NAME | Ramineh |
| AGENT ATTORNEY ADDRESS1 | One Financial Center |
| AGENT ATTORNEY ADDRESS2 | 41st Floor |
| AGENT ATTORNEY CITY | Boston |
| AGENT ATTORNEY STATE | MA |
| AGENT ATTORNEY POSTAL CODE | 2111 |
| AGENT ATTORNEY COUNTRY | UNITED STATES OF AMERICA |
| AGENT ATTORNEY PROVINCE | |
| AGENT ATTORNEY PHONE | 14242594024 |
| AGENT ATTORNEY PHONE EXT | |
| AGENT ATTORNEY EMAIL ADDRESS | arbahar@mintz.com |
| LAWFIRM NAME BUSINESS NAME | Mintz |
| STATE OF HIGHEST COURT | CA |
| NAME OF HIGHEST STATE COURT | Supreme Court of CA |
| WORKSITE WORKERS | 1 |
| SECONDARY ENTITY | No |
| SECONDARY ENTITY BUSINESS NAME | |
| WORKSITE ADDRESS1 | 793 Heinz Avenue |
| WORKSITE ADDRESS2 | |
| WORKSITE CITY | Berkeley |
| WORKSITE COUNTY | ALAMEDA |
| WORKSITE STATE | CA |
| WORKSITE POSTAL CODE | 94710 |
| WAGE RATE OF PAY FROM | $156,000.00 |
| WAGE RATE OF PAY FROM CLEANED | |
| WAGE RATE OF PAY TO | |
| WAGE UNIT OF PAY | Year |
| PREVAILING WAGE | $155,750.00 |
| PW UNIT OF PAY | Year |
| PW TRACKING NUMBER | |
| PW WAGE LEVEL | IV |
| PW OES YEAR | 7/1/2024 - 6/30/2025 |
| PW OTHER SOURCE | |
| PW OTHER YEAR | |
| PW SURVEY PUBLISHER | |
| PW SURVEY NAME | |
| TOTAL WORKSITE LOCATIONS | 2 |
| AGREE TO LC STATEMENT | Yes |
| H 1B DEPENDENT | No |
| WILLFUL VIOLATOR | No |
| SUPPORT H1B | N/A |
| STATUTORY BASIS | |
| APPENDIX A ATTACHED | N/A |
| PUBLIC DISCLOSURE | Disclose Business |
| PREPARER LAST NAME | Garcia |
| PREPARER FIRST NAME | Karolline |
| PREPARER MIDDLE INITIAL | B |
| PREPARER BUSINESS NAME | Mintz |
| PREPARER EMAIL | kbgarcia@mintz.com |
| BEGIN DATE CONVERTED | 2024-10-21 |
