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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).