Form ETA-9155 H-2B Registration

O MB Approval: 1205-0509

Expiration Date: 10/31/2015

H-2B Registration

Form ETA-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 registrations and registrations unable to establish that the employer’s need for services or labor is temporary in nature 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. Emergency Filing

1. Is this registration being submitted in support of an emergency filing under 20 CFR 655.17? *

 Yes  No

B. Temporary Need Information

1. Job Title *
2. SOC (ONET/OES) code *	3. SOC (ONET/OES) occupation title *
4. Job duties – A description of the duties to be performed MUST begin in this space. If necessary, add attachments to continue and complete description. *
5. Total workers employed in this position on a permanent, year round basis? *	Period of Intended Employment
	6. Begin Date * (mm/dd/yyyy)	7. End Date * (mm/dd/yyyy)
8. Total worker positions requested for temporary labor certification in the first registration year *
9. Nature of Temporary Need: (Choose only one of the standards) *  Seasonal  Peakload  One-Time Occurrence  Intermittent or Other Temporary Need
10. Statement of Temporary Need – A justification that the need for the services or labor to be performed is temporary in nature, MUST begin in this space. If necessary, add attachments to continue and complete the justification. *

1B. Temporary Need Information (continued)

11. Worksite address 1 *
12. Address 2
13. City *	14. County *
15. State/District/Territory *	16. Postal code *
17. Will work be performed in multiple worksites within an area of intended employment or a location(s) other other than the address listed above? *		 Yes  No
17a. If Yes in question 17, identify each geographic place(s) of employment with as much specificity as possible. If necessary, submit an attachment to continue and complete a listing of all anticipated worksites. §

C. Employer Information

Important Note: Enter the full name of the individual employer, job contractor, 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 *			11. Extension
12. Federal Employer Identification Number (FEIN from IRS) *		13. NAICS code (must be at least 4-digits) *
14. Number of non-family full-time equivalent employees *	15. Annual gross revenue *		16. Year established *
17. Type of employer seeking registration in the H-2B program (check only one box) *		 Individual Employer  Job Contractor  Joint Employer

D. 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 H-2B registration and labor certification matters. The information in this Section must be different from the agent or attorney information listed in Section E, 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 *	13. Extension	14. E-Mail address

E. Attorney or Agent Information (If applicable)

1. Is/are the employer(s) represented by an attorney or agent in the filing of this application (including an association acting as an agent under the H-2B program)? If “Yes”, complete Section E. *								 Yes  No
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 §	13. Extension		14. E-Mail address
15. Law firm/Business name §					16. Law firm/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) §

F. Declaration of Employer and Attorney/Agent

a. 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).

1. Last (family) name of hiring or designated official *	2. First (given) name of hiring or designated official *		3. Middle initial
4. Hiring or designated official title *
5. Signature *		6. Date signed (mm/dd/yyyy) *

b. Attorney/Agent

I hereby declare under penalty of perjury that I have prepared this request for H-2B registration at the direct request of the employer listed in Section C 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).

1. Attorney or Agent’s last (family) name §	2. First (given) name §		3. Middle initial
4. Title§
5. Signature §		6. Date signed (mm/dd/yyyy) §

G. Preparer

Complete this section if the preparer of this application is a person other than the one identified in either Section D (employer point of contact) or E (attorney or agent) of this application.

1. Last (family) name §	2. First (given) name §	3. Middle initial
4. Title §
5. Firm/Business name §
6. E-Mail address §

H. U.S. Department of Labor Registration Decision

FOR OFFICIAL GOVERNMENT USE ONLY
Registration tracking number		2. Date registration request received
3. SOC (ONET/OES) code	3a. SOC (ONET/OES) occupation title
2. Decision status		3. Date registration decision issued
4. Total Worker Positions Approved	Approval Period of H-2B Registration
	5. Begin Date		6. End Date
7. Additional Notes Regarding Registration Decision

OMB Paperwork Reduction Act (1205-0509)

Persons are not required to respond to this collection of information unless it displays a currently valid OMB control number. 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. The obligation to respond to this data collection is required to obtain/retain benefits (Immigration and Nationality Act, 8 U.S.C. 1101, et seq.). Please send comments regarding this burden estimate or any other aspect of this information collection to the Office of Foreign Labor Certification ● U.S. Department of Labor ● Room C4312 ● 200 Constitution Ave., NW, ● Washington, DC 20210. Please do not send the completed H-2B Registration to this address.

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

Registration Number: ______________________ Decision: __________________ Approval Period: ______________ to _______________