ETA 9142C Appendix Form ETA-9142C – Appendix B

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

1. City *

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

2. State *

3. Postal Code *

5. Additional Work Itinerary Information §

4. Additional Place of Employment
Information §

Crew
Total
ID
Workers

Begin Date

End Date

Basic Wage Rate
From:

To:

Per

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 information 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 i nf o r ma t i on . Th e
burden estimate is as follows: 9142C - 45 minutes, Appendix A - 15 minutes, Appendix B - 20 minutes, Appendix C - 20 minutes, and recordkeeping - 10 minutes. The obligation to respond to this data collec ti o n i s r e q u i r e d t o
obtain/retain benefits (Northern Mariana Islands U.S. Workforce Act of 2018, 48 U.S.C. 1806 et seq.). Please send comments regarding this 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 Certification * 200 Constitution Ave., NW * Box PPII 12-200 * Washington, DC * 20210 or by email to [email protected]. Please do not s e nd
the completed application to this address.

Form ETA-9142C, Appendix B
CW-1 Case Number: ____________________

FOR DEPARTMENT OF LABOR USE ONLY
Case Status: _______________________

Determination Date: _____________

P age B.1 of B.1
Validity Period: _____________ to _____________