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

O MB Approval: 1205-053X

Expiration Date: XX/XX/XXXX

H-2B Application for Temporary Employment Certification

Form ETA 9142B

U.S. Department of Labor

A job contractor means a person, association, firm, or a corporation that meets the definition of an employer and that contracts services or labor 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 contractor will not exercise substantial, direct day-to-day supervision and control in the performance of the services or labor to be performed other than hiring, paying, and firing the workers. 20 CFR 655.402, 655.421. Pursuant to 20 CFR 655.421(a), a job contractor may only submit 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 Temporary Employment 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 Sections A and B below and attach this form to the Form ETA-9142C that will be submitted to the Department for processing.

1. Employer-Client Information

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 *	7. Postal Code *
8. Country *	9. Province §
10. Telephone Number *	11. Extension §
12. Federal Employer Identification Number (FEIN from IRS) *	13. NAICS Code *

B. Employer-Client Point of Contact Information

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 *	9. Postal Code *
10. Country *				11. Province §
12. Telephone Number *	13. Extension §		14. Business Email Address *

Public Burden Statement (1205-0534)

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 information.  The 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 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 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 send the completed application to this address.

FOR DEPARTMENT OF LABOR USE ONLY Case Number: __________________ Case Status: __________________ Page 2 of 1