Appendix A Tracked

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

DRAFT
For public burden statement information, please see Form ETA-9142B General Instructions.
Public Burden Statement (1205-0509)
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 2 hours and 10 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:
9142B- 55 minutes, Appendix A- 15 minutes, Appendix B- 15 minutes, Appendix C- 20 minutes, Appendix D- 10 minutes, and recordkeeping- 15 minutes. The obligation to respond to this data collection is required to obtain/retain benefits
(Immigration and Nationality Act, 8 U.S.C. 1101 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-9142B
H-2B Case Number: ______________________

FOR DEPARTMENT OF LABOR USE ONLY
Case Status: _______________________

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

Validity Period: _____________ to _____________