Form ETA-9142B Appendix D 1205-0509 clean

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

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

A job contactor 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, which is 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 655.5. Pursuant to 20 CFR 655.19(a), a
job contractor may only submit an H-2B Application for Temporary Employment Certification, Form ETA 9142B, 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 655.5. Pursuant to 20 CFR 655.19(d)(1), a job contractor
that is filing as a joint employer with its employer-client must submit a completed H-2B Application for Temporary Employment Certification, Form ETA 9142B, that clearly
identifies the joint employers (the job contractor and its employer-client) and the employment relationship (including the actual worksite(s) disclosed on the Form ETA9142B). Please complete Sections A and B below and attach this form to the Form ETA 9142B that will be submitted to the Department for processing. In addition to
completing Appendix D, joint employer entities and job contractors and their employer end-clients must each submit Appendix B attestations.

A. Employer-Client or Joint 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 *

8. Country *

9. Province §

10. Telephone Number *

11. Extension §

12. Federal Employer Identification Number (FEIN from IRS) *

13. NAICS Code *

7. Postal Code *

B. Employer-Client or Joint Employer 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 *

10. Country *

11. Province §

12. Telephone Number *

9. Postal Code *

13. Extension § 14. Business Email Address *

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 D.1 of D.1
Validity Period: _____________ to _____________