Appendix C Tracked

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 *

7. Postal Code *

2. First (given) Name *

3. Middle Name(s) §

4. Name of Employer/Recruiting Organization *
6. State *

8. Country *

AF
T

5. City *

7. Postal Code *

9. Province §

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

2. First (given) Name *

3. Middle Name(s) §

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

6. State *

9. Province §

R

8. Country *

7. Postal Code *

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

2. First (given) Name *

3. Middle Name(s) §

5. City *
8. Country *

D

4. Name of Employer/Recruiting Organization *

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

6. State *

7. Postal Code *

9. Province §

2. First (given) Name *

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.
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: __________________

Determination Date: _____________

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