Form ETA-9142B Appendix A 1205-0509 clean

OMB Approval: 1205-0509
Expiration Date: 05/31/2022

1. City *

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

2. State *

3. County *

4. MSA Name/OES Area Title *

5. Additional Place of Employment
Information §

6. Additional Work Itinerary Information §
Crew
Total
Begin Date End Date
ID Workers

Basic Wage Rate
From:

To:

Per

For public burden statement information, please see Form ETA-9142B General Instructions.

Form ETA-9142B
H-2B Case Number: ______________________

FOR DEPARTMENT OF LABOR USE ONLY
Case Status: _______________________

Page A.1 of A.1
Determination Date: _____________

Validity Period: _____________ to _____________