ETA 9105 Employer Data Form

U.S. Department of Labor OMB Control No. 1205-0439

Employment and Training Administration Expiration Date: XX/XX/XXXX

Employer Data Form ETA 9105

National Dislocated Worker Grant Electronic Application System

Company/Industry	Location of Facility	Notification Type	Date of Notification	Layoff Date(s)	Number of Affected Workers
					Closure:

Dates(s) of Rapid Response Actions	Number of Workers Contacted	Field Surveys Completed	TAA Petition	Number of Planned Participants	Labor Organization Representation
Contact with Employer: Contact with Workers:			Date Filed: Number of Workers Covered: Not Applicable:

Type of Business:

Two-Digit NAIC Code:

Public Burden Statement:

Persons are not required to respond to this collection of information unless it displays a currently valid OMB Control number. Respondents’ obligation to complete this form is required to obtain or retain benefits (PL: 113-128 sec170). Public reporting burden for this collection of information is estimated to average 30 minutes 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. This is public information and there is no expectation of confidentiality. Send comments regarding this burden estimate to the U.S. Department of Labor, Office of National Response, Room C-5311, Washington, D.C. 20210 (Paperwork Reduction Project 1205-0439).