Form ETA 9142A ETA 9142A H-2A Application for Temporary Employment Certification

OMB Approval: 1205-0466
Expiration Date: XX/XX/XXXX

H-2A Application for Temporary Employment Certification
Form ETA-9142A
U.S. Department of Labor

IMPORTANT: Employers and authorized preparers must read the general instructions carefully before completing the Forms ETA-9142A and ETA-790/790A. A copy of
the instructions can be found on the Office of Foreign Labor Certification website at https://www.dol.gov/agencies/eta/foreign-labor/forms. If you are not submitting these
forms electronically, please complete ALL required fields/items containing an asterisk ( * ) and any fields/items where a response is conditional as indicated by the section
( § ) symbol.

A. Nature of H-2A Application
1. Type of Employer Application (choose only one)*

 Individual Employer

 Joint Employer (2 or more individual employers)

1a. Agricultural Association Employer or Agency Status, if applicable (choose only one) §

 Association – Sole Employer

2.
3.
4.

 Association - Joint Employer

 Association - Agent
Is the employer operating as an H-2A Labor Contractor (H-2ALC), as defined by 20 CFR 655.103(b)? *
 Yes  No
Nature of Temporary Need (choose only one) *
 Seasonal  Other Temporary Need
Is a statement of temporary need attached to this application? *
 Yes  No

5. Is this application being filed with a request to waive the regulatory time period due to an emergency
situation, as defined by 20 CFR 655.134? *
6. If “Yes” is marked in question A.5, a statement justifying the employer’s emergency situation is attached
this application. *

 Yes  No
 Yes  N/A

B. Employer 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 *

C. Employer Point of Contact Information
The information contained in this Section must be that of an employee of the employer who is authorized to act on behalf of the employer in labor certification matters.
The information in this Section must be different from the agent or attorney information listed in Section D, unless the attorney is an employee of the employer.

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 *

10. Country *

11. Province §

12. Telephone Number *

Form ETA-9142A
H-2A Case Number: __________________

13. Extension §

14. Business Email Address *

FOR DEPARTMENT OF LABOR USE ONLY
Case Status: __________________

9. Postal Code *

Determination Date: _____________

Page 1 of 3
Validity Period: _____________ to _____________

OMB Approval: 1205-0466
Expiration Date: 08/31/2022

H-2A Application for Temporary Employment Certification
Form ETA-9142A
U.S. Department of Labor

D. Attorney or Agent Information (If applicable)
1. Indicate the type of representation for the employer in the filing of this application. *
Complete the remainder of this section if “Attorney” or “Agent” is marked.
2. Attorney or Agent’s Last (family) Name §
3. First (given) Name §

 Attorney  Agent  None
4. Middle Name(s) §

5. Address 1 §
6. Address 2 (apartment/suite/floor and number) §
7. City §

8. State §

10. Country §

11. Province §

12. Telephone Number §

13. Extension §

9. Postal Code

14. Law Firm/Business Email Address §

15. Law Firm/Business Name §

16. Law Firm/Business FEIN §

If “Attorney” is marked in question D.1, complete questions 17 – 19 below.
17. State Bar Number(s) §
18. State of highest court where attorney is in good standing §
19. Name of the highest state court where attorney is in good standing §
If “Agent” is marked in question D.1, complete questions 20 and 21 below.
20. A copy of the current agreement or other documentation demonstrating the agent’s authority to
represent the employer in this application is attached to this application. §

 Yes

21. A copy of the agent’s current Migrant and Seasonal Agricultural Worker Protection Act (MSPA)
Certificate of Registration identifying the farm labor contracting activities the agent is authorized to
perform is attached to this application. §

 Yes  N/A

E. Job Opportunity & Supporting Documentation
1. SOC Occupational Code *

2. SOC Occupational Title *

3. A copy of the completed job order (Form ETA-790/790A) satisfying the requirements at 20 CFR
653, subpart F, and 20 CFR 655, subpart B, is attached to this application. *
4. If “Joint Employer” is marked in question A.1, the Form ETA-790A and Addendum B identify the
name(s), address(es), total number of workers needed, and crops and agricultural work of each
employer that will employ workers. §

 Yes
 Yes

 N/A

For H-2A Labor Contractors ONLY
If “Yes” is marked in question A.2, complete questions E.5 through E.9 below
5. The Form ETA-790A, Addendum B, identifies the name(s) and location(s) of each fixed-site
agricultural business the employer will be providing H-2A workers, the expected first and last dates
of work for each business, and a description of crops and activities the workers will perform. §
6. A copy of fully-executed work contract(s) with each fixed-site agricultural business identified on the
Form ETA-790A, Addendum B, is attached to this application. §
7. A copy of the employer’s valid MSPA Certificate of Registration identifying the farm labor contracting
activities the employer is authorized to perform is attached to this application. §
8. A signed and dated Appendix B, H-2A Labor Contractor Surety Bond, for the employer identified in Se
B of this application is attached. §
9. Will any of the fixed-site agricultural businesses provide workers with housing and/or transportation
between the place of employment and the living quarters under this application? §
Form ETA-9142A
H-2A Case Number: __________________

FOR DEPARTMENT OF LABOR USE ONLY
Case Status: __________________

Determination Date: _____________

 Yes  No
 Yes  No
 Yes  No
 N/A
 Yes  No
 Yes  No
Page 2 of 3

Validity Period: _____________ to _____________

OMB Approval: 1205-0466
Expiration Date: 08/31/2022

H-2A Application for Temporary Employment Certification
Form ETA-9142A
U.S. Department of Labor

F. Declaration of Employer and Attorney/Agent
In accordance with Federal regulations, the employer(s) must attest to abide by certain terms, assurances, and obligations as a condition for receiving a temporary labor
certification from the U.S. Department of Labor. Applications that fail to attach Appendix A will be considered incomplete and rejected without further review.

1. A signed and dated Appendix A for the employer identified in Section B of this application is
attached. *
2. Except for agricultural associations filing as a joint employer, a separate signed and dated
Appendix A for each employer identified as a joint employer on the job order (Form ETA-790/790A)
is attached. *

 Yes
 Yes  N/A

G. Preparer
Complete this section if the preparer of this application is a person other than the one identified in either Section C (employer point of contact) or D (attorney or agent) of
this application.

1. Last (family) Name §
4. Law Firm/Business FEIN §

2. First (given) Name §

3. Middle Initial §

5. Law Firm/Business Name §

6. Business Email Address §

For Public Burden Statement, see the Instructions for Form ETA-9142A.

Form ETA-9142A
H-2A Case Number: __________________

FOR DEPARTMENT OF LABOR USE ONLY
Case Status: __________________

Determination Date: _____________

Page 3 of 3
Validity Period: _____________ to _____________