ETA 9142C Appendix Form ETA-9142C – Appendix A

OMB Approval: 1205-053X
Expiration Date: XX/XX/XXXX

CW-1 Application for Temporary Employment Certification
Form ETA-9142C – Appendix A
U.S. Departm ent of Labor

A job contractor means a person, association, firm, or a corporation that meets the definition of an employer and that contracts service s o r l a b o r
on a temporary basis to one or more employers that are not an affiliate, branch, or subsidiary of the job contractor and where the job co n tra ct o r
will not exercise substantial, direct day-to-day supervision and control in the performance of the services or labor t o b e p e rf o rm e d o t h e r t h a n
hiring, paying, and firing the workers. 20 CFR 655.402, 655.421. Pursuant to 20 CFR 655.421(a), a job contra c t or m a y o n ly su b m i t a CW-1
Application for Temporary Employment Certification, Form ETA 9142C, if it is filing as a joint employer with its employer-client. An employer-client
means an employer that has entered into an agreement with a job contractor, as defined in 20 CFR 655.402. Pursuant to 20 CFR 655.421(d)(1 ),
a job contractor that is filing as a joint employer with its employer-client must submit a completed CW-1 Application for Tempo ra ry E mp l o yme n t
Certification, Form ETA 9142C, that clearly identifies the joint employers (the job contractor and its employer-client) and the employment
relationship (including the actual place(s) of employment disclosed on the Form ETA-9142C). Please complete Se c t io ns A a n d B b e l o w a n d
attach this form to the Form ETA 9142C that will be submitted to the Department for processing.

A. Em ployer-Client Inform ation
1. Legal Business Name *
2. Trade Name/Doing Business As (DBA), if applicable §
3. Address 1 *
4. Address 2 § (apartment/suite/floor and number)
5. City *

6. State *

8. Country *

9. Province §

10. Telephone Number *

11. Extension §

12. Federal Employer Identification Number (FEIN from IRS) *

13. NAICS Code *

7. Postal Code *

B. Em ployer-Client Point of Contact Inform ation
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 § (apartment/suite/floor and number)
7. City *

8. State *

10. Country *

11. Province §

12. Telephone Number *

9. Postal Code *

13. Extension § 14. Business Email Address *

Public Burden Statement (1205-053X)
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 inf ormation is estimated to average 1 hour and 50 minutes to complete the form and its appendices, including the time for reviewing instructions, searching existing
data sources, gathering and maintaining the needed data, and completing and reviewing the collection of information. The burden estimate is as follows: 9142C - 4 5
minutes, Appendix A - 15 minutes, Appendix B - 20 minutes, Appendix C - 20 minutes, and recordkeeping - 10 minutes. The obligati o n t o r e sp o n d t o t h i s d a t a
collection is required to obtain/retain benefits (Northern Mariana Islands U.S. Workforce Act of 2018, 48 U.S.C. 1806 et seq.). Please send comments regarding th i s
burden estimate or any other aspect of this information collection to the U.S. Department of Labor * Employment and Training Administration * Office of Foreign Labor
Certif ication * 200 Constitution Ave., NW * Box PPII 12-200 * Washington, DC * 20210 or by email to ETA.OFLC.F or m s@d o l .g ov . P l ea s e do n ot s e nd t h e
completed application to this address.
Form ETA-9142C, Appendix A
CW-1 Case Number: __________________

FOR DEPARTMENT OF LABOR USE ONLY
Case Status: __________________

Determination Date: _____________

P age A.1 of A.1
Validity Period: _____________ to ____________