ETA 9155 H2B Registration

O MB Approval: 1205-0466

Expiration Date: 11/30/2011

H-2B Registration

ETA Form 9155

U.S. Department of Labor

Please read and review the filing instructions carefully before completing the ETA Form 9155. A copy of the instructions can be found at http://www.foreignlaborcert.doleta.gov/. In accordance with Federal Regulations, incomplete or obviously inaccurate forms will not be approved by the Department of Labor. If submitting this form non-electronically, ALL required fields/items containing an asterisk ( * ) must be completed as well as any fields/items where a response is conditional as indicated by the section ( § ) symbol.

A. Employer Information

Important Note: Enter the full name of the individual employer, partnership, or corporation and all other required information in this section.

1. Legal business name *
2. Trade name/Doing Business As (DBA), if applicable
3. Address 1 *
4. Address 2
5. City *		6. State *			7. Postal code *
8. Country *		9. Province
10. Telephone number *		10a. Extension		11. Fax number*
12. Federal Employer Identification Number (FEIN from IRS) *		13. NAICS code (must be at least 4-digits) *
14. Is the employer filing under special procedures?*  Yes  No
14a. If “yes” in question 14, please indicate which special procedures: §
15. Is the employer a subsidiary or branch of a parent company?*  Yes  No
15a. If “yes” in question 15, please provide the name of the parent company. §
16. Has the employer ever filed an application with OFLC under a different business name?*  Yes  No
16a. If “yes” in question 16, please provide the name of the other business: §
17. Number of full-time equivalent employees*	18. Annual gross revenue*		19. Year established*

B. Emergency Filing

1. Is the employer filing under emergency procedures?*  Yes  No

2. If “yes” in question 1, please explain why emergency procedures are necessary. §

C. Temporary Need Information

1. Job Title *
2. SOC (ONET/OES) code *	3. SOC (ONET/OES) occupation title *
4. Describe Job Duties*
5. Number of positions to be requested in the first year of registration *		6. Anticipated Period of Employment *
		From (mm/dd)	To (mm/dd)
7. Nature of Temporary Need: (Choose only one of the standards) *  Seasonal  Peakload  One-Time Occurrence  Intermittent or Other Temporary Need
8. Statement of Temporary Need *
Note: The employer must submit documentation demonstrating its temporary need along with this request for H-2B registration.

D. Place of Employment Information

1. Worksite address 1 *
2. Address 2
3. City *	4. County *
5. State/District/Territory *	6. Postal code *

E. Employer Point of Contact Information

Important Note: The information contained in this Section must be that of an employee of the employer who is authorized to act on behalf of the employer in labor certification matters. The information in this Section must be different from the agent or attorney information listed in Section F, unless the attorney is an employee of the employer.

1. Contact’s last (family) name *		2. First (given) name *		3. Middle name(s) *
4. Contact’s job title *
5. Address 1*
6. Address 2
7. City *			8. State *	9. Postal code *
10. Country *			11. Province
12. Telephone number *	12a. Extension		13. Fax number *
14. E-mail address *			14a. Alternate e-mail address §
Preferred method of contact *  Mail (non-electronic)  Electronic mail (e-mail)

F. Attorney or Agent Information (If applicable)

In the filing of this request for H-2B registration, is the employer represented by an :  attorney or  agent ? If represented by an attorney or agent, complete the information below and attach a letter demonstrating authority to represent the employer. §
2. Attorney or Agent’s last (family) name §		3. First (given) name §				4. Middle name(s) §
5. Address 1 §
6. Address 2
7. City §			8. State §				9. Postal code §
10. Country §			11. Province §
12. Telephone number §	12a. Extension		13. Fax number §
14. E-Mail address §
15. Law firm/Agent’s Business name §					16. Law firm/Agent’s Business FEIN §
17. State Bar number (only if attorney) §				18. State of highest court where attorney is in good standing (only if attorney) §
19. Name of the highest court where attorney is in good standing (only if attorney) §

G. Declarations

a. Preparer

1. Was the application completed by someone other than the person signing on behalf of the employer in item G.c. below or the attorney/agent listed in section F? § If “yes” you must complete the remainder of section G.a. or G.b. as appropriate.

 Yes  No

I hereby certify that I have prepared this request for H-2B registration at the direct request of the employer listed in Section A or the Attorney/Agent listed in Section F and that to the best of my knowledge the information contained herein is true and correct. I understand that to knowingly furnish false information in the preparation of this form and any supplement thereto or to aid, abet, or counsel another to do so is a felony punishable by a $250,000 fine or 5 years in a Federal penitentiary or both (18 U.S.C. 1001).

2a. Preparer’s last (Family) name 2b. First (Given) name 2c. Middle initial §
3. Title§
4. Business or Law Firm name§
5. Address (if not listed elsewhere on this application) §
6. City §	7. State §	8. Postal code §
9. Country §	10. Province §	11. E-mail address§
12. Signature §			13. Date signed (mm/dd/yyyy§)

b. Attorney/Agent

Unless the attorney or agent listed in Section F prepared this request for H-2B registration and completed the information above, he or she must complete this section.

I hereby certify that I have prepared this request for H-2B registration at the direct request of the employer listed in Section A and that to the best of my knowledge the information contained herein is true and correct. I understand that to knowingly furnish false information in the preparation of this form and any supplement thereto or to aid, abet, or counsel another to do so is a felony punishable by a $250,000 fine or 5 years in a Federal penitentiary or both (18 U.S.C. 1001).

1a. Attorney/Agent’s last (Family) name 1b. First (Given) name 1c. Middle initial§
2. Title§
3. Signature §	4. Date signed (mm/dd/yyyy) §

?

c. Employer

I declare under penalty of perjury that I have read and reviewed this request for H-2B registration and that to the best of my knowledge the information contained therein is true and accurate. I understand that to knowingly furnish false information in the preparation of this form and any supplement thereto or to aid, abet, or counsel another to do so is a felony punishable by a $250,000 fine or 5 years in the Federal penitentiary or both (18 U.S.C. 1001).

1a. Last (Family) name 1b. First (Given) name 1c. Middle initial *
2. Title *
3. Signature *	4. Date signed (mm/dd/yyyy) *

H. OMB Paperwork Reduction Act (1205-0466)

Persons are not required to respond to this collection of information unless it displays a currently valid OMB control number. Respondent’s reply to these reporting requirements is mandatory to obtain the benefits of temporary employment certification (Immigration and Nationality Act, Section 101 (a)(15)(H)(ii)). Public reporting burden for this collection of information is estimated to average 1 hour per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate to the Office of Foreign Labor Certification * U.S. Department of Labor * Room C4312 * 200 Constitution Ave., NW * Washington, DC * 20210. Do NOT send the completed request for H-2B registration to this address.

ETA Form 9155 FOR DEPARTMENT OF LABOR USE ONLY Page 5 of 5

Registration Number: ____________________ Registration Status: __________________ Validity Period: ______________ to _____________