Form ETA-9142B Appendix C 1205-0509 clean

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

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

Pursuant to 20 CFR 655.9(b), the employer, and its attorney or agent (as applicable), must provide the identity and location of all persons and entities hired by or working
for the recruiter or agent, and any of the agent(s) or employee(s) of those persons and entities, to recruit prospective foreign workers for the H-2B job opportunities offered
by the employer under this H-2B Application for Temporary Employment Certification, Form ETA-9142B. Please complete each section of “Foreign Labor Recruiter
Information” below. If the employer has more than five (5) persons and entities to identify, the employer must disclose as many additional “Foreign Labor Recruiter
Information” sections as are necessary to list all persons or entities engaged in foreign worker recruitment for this application.

Foreign Labor Recruiter Information 1
1. Recruiter’s Last (family) Name *

2. First (given) Name *

3. Middle Name(s) §

4. Name of Employer/Recruiting Organization *
5. City *

6. State *

8. Country *

9. Province §

Foreign Labor Recruiter Information 2
1. Recruiter’s Last (family) Name *

2. First (given) Name *

7. Postal Code *

3. Middle Name(s) §

4. Name of Employer/Recruiting Organization *
5. City *

6. State *

8. Country *

9. Province §

Foreign Labor Recruiter Information 3
1. Recruiter’s Last (family) Name *

2. First (given) Name *

7. Postal Code *

3. Middle Name(s) §

4. Name of Employer/Recruiting Organization *
5. City *

6. State *

8. Country *

9. Province §

Foreign Labor Recruiter Information 4
1. Recruiter’s Last (family) Name *

2. First (given) Name *

7. Postal Code *

3. Middle Name(s) §

4. Name of Employer/Recruiting Organization *
5. City *

6. State *

8. Country *

9. Province §

Foreign Labor Recruiter Information 5
1. Recruiter’s Last (family) Name *

2. First (given) Name *

7. Postal Code *

3. Middle Name(s) §

4. Name of Employer/Recruiting Organization *
5. City *

6. State *

8. Country *

9. Province §

7. Postal Code *

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: __________________

Determination Date: _____________

Page C.1 of C.1
Validity Period: _____________ to _____________