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

OMB Approval: 1205-0534

Expiration Date: 09/30/2019

CW-1 Application for Temporary Employment Certification

Form ETA-9142C - Appendix B

U.S. Department of Labor

City *	Postal/ZIP Code *	Additional Place of Employment Information § (Address—e.g., street address, area, town, village, geographic identification)	Additional Work Itinerary Information §
			Crew ID	Total Workers	Begin Date	End Date	Basic Wage Rate (in $)		Per
							From:	To:

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.

Form ETA-9142C -Appendix B FOR DEPARTMENT OF LABOR USE ONLY Page B.1 of B.1

CW-1 Case Number: ____________________ Case Status: _______________________ Determination Date: _____________ Validity Period: _____________ to _____________