Appendix D Tracked

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 ETA-9142B). 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

DRAFT

1. Contact’s Last (family) Name *
4. Contact’s Job Title *
5. Address 1 *

2. First (given) Name *

3. Middle Name(s) §

6. Address 2 § (apartment/suite/floor and number)
7. City *

8. State *

10. Country *
12. Telephone Number *

9. Postal Code *

11. Province §
13. Extension § 14. Business Email Address *

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 D.1 of D.1

Validity Period: _____________ to _____________