ETA-9142A - Append Appendix A

OMB Approval: 1205-0466
Expiration Date: 5/31/2019

H-2A Application for Temporary Employment Certification
Form ETA-9142A – APPENDIX A
U.S. Department of Labor

For Use in Filing Applications Under the H-2A Agricultural Program ONLY
A. Attorney or Agent Declaration
I hereby certify that I am an employee of, or hired by, the employer listed in Section C of the Form ETA-9142A, and that I have
been designated by that employer to act on its behalf in connection with this application. If I am an agent and not an
employee of the employer, then I have attached a Letter of Representation from the employer. I also certify that to the best of
my knowledge the information contained herein is true and correct. I understand that to knowingly furnish false information in the
preparation of this form and any supplement hereto or to aid, abet, or counsel another to do so is a felony punishable by a $250,000
fine or 5 years in a Federal penitentiary or both (18 U.S.C. 1001).

1. Attorney or Agent’s last (family) name

2. First (given) name

3. Middle initial

4. Firm/Business name
5. E-Mail address
6. Signature

7. Date signed

B. Employer Declaration
By virtue of my signature below, I HEREBY CERTIFY the following conditions of employment:
1.

The job opportunity is a full-time temporary position, the qualifications for which do not substantially deviate from the normal
and accepted qualifications required by non-H-2A employers in the same or comparable occupations and crops.

2.

The specific job opportunity for which the employer is requesting H-2A certification is not vacant because the former
occupant(s) is (are) on strike or locked out in the course of a labor dispute involving a work stoppage.

3.

The job opportunity is open to any qualified U.S. worker regardless of race, color, national origin, age, sex, religion, handicap, or
citizenship, and the employer has conducted and will continue to conduct the required recruitment, in accordance with regulations,
and has been unsuccessful in locating sufficient numbers of qualified U.S. applicants for the job opportunity for which certification is
sought. Any U.S. workers who applied or apply for the job were or will be rejected only for lawful, job-related reasons, and the
employer must retain records of all rejections as required by 20 CFR 655.167.

4.

The job opportunity offers U.S. workers no less than the same benefits, wages, and working conditions that the employer is
offering, intends to offer, or will provide to H-2A workers and complies with the requirements at 20 CFR 655, Subpart B.

5.

The employer understands that it must offer, recruit at, and pay a wage that is at least the highest of the adverse effect wage
rate in effect at the time the job order is placed, the prevailing hourly or piece rate, the agreed-upon collective bargaining rate
(CBA), or the Federal or State minimum wage, and, furthermore, that if a new Adverse Effect Wage Rate is published, or the
employer is notified of a new prevailing wage rate during the contract period, and that new rate is higher than the wage
determined by the NPC (except the CBA) during the application process the employer will increase the pay of all employees in
the same job occupation to the higher rate. For employers subject to the requirements at 20 CFR 655.200-235, the employer
understands that it must offer, recruit at, and pay a wage that is at least the highest of the adverse effect wage rate, the
agreed-upon CBA, or the applicable minimum wage rate set by Federal or State law or judicial action, for each month, or
portion thereof, during the job order period.

6.

There are no U.S. workers available in the area(s) capable of performing the temporary services or labor in the job
opportunity, and the employer will conduct positive recruitment as specified by the NPC and continue to cooperate with the
SWA by accepting referrals of all eligible U.S. workers who apply (or on whose behalf an application is made) for the job
opportunity until completion of 50% of the contract period calculated from the first date of need indicated in Section B.5 of
Form ETA-9142A.

7.

All fees associated with processing the temporary labor certification will be paid in a timely manner.

Form ETA-9142A – Appendix A TO BE COMPLETED BY EMPLOYER FROM A CERTIFIED FORM ETA-9142A

Page A.1 of A.3

Case Number:___________________ Case Status: __________________ Period of Employment: ______________ to _______________

OMB Approval: 1205-0466
Expiration Date: 5/31/2019

H-2A Application for Temporary Employment Certification
Form ETA-9142A – APPENDIX A
U.S. Department of Labor
8.

During the period of employment that is the subject of the labor certification application, the employer:
(i) Will comply with applicable Federal, State and local employment-related laws and regulations, including
employment-related health and safety laws;
(ii) Will provide for or secure housing for workers who are not reasonably able to return to their permanent residence at
the end of the work day that complies with the applicable local, State, or Federal standards and guidelines for
housing without charge to the worker;
(iii) Where required, has timely requested a preoccupancy inspection of the housing and received certification;
(iv) Will provide insurance, without charge to the worker, under a State workers' compensation law or otherwise, that
meets the requirements of 20 CFR 655.122(e).
(v) Will provide transportation in compliance with all applicable Federal, State or local laws and regulations between the
worker's living quarters (i.e., housing provided by the employer under 20 CFR 655.122(d) and, if applicable, 655.230)
and the employer's worksite without cost to the worker.
(vi) Will provide all tools, supplies, and equipment required to perform the duties, without charge to the worker.
(vii) Will provide meals and potable water, without charge to the worker, if subject to the requirements at 20 CFR
655.200-235.

9.

The employer has not laid off and will not lay off any similarly employed U.S. worker in the occupation that is the subject of the
H-2A Application for Temporary Employment Certification in the area of intended employment except for lawful, job related
reasons within 60 days of the date of need, or if the employer has laid off such workers, it has offered the job opportunity that is
the subject of the application to those laid-off U.S. worker(s) and the U.S. worker(s) refused the job opportunity, was rejected
for the job opportunity for lawful, job-related reasons, or was hired.

10. The employer and its agents have not sought or received payment of any kind from the H-2A worker for any activity related to
obtaining labor certification, including payment of the employer's attorneys' fees, application fees, or recruitment costs. For
purposes of this paragraph, payment includes, but is not limited to, monetary payments, wage concessions (including
deductions from wages, salary, or benefits), kickbacks, bribes, tributes, in kind payments, and free labor.
11. The employer has and will contractually forbid any foreign labor contractor or recruiter whom the employer engages in
international recruitment of H-2A workers to seek or receive payments from prospective employees, except as provided for in
DHS regulations.
12. The employer has not and will not intimidate, threaten, restrain, coerce, blacklist, or in any manner discriminate against, and
has not and will not cause any person to intimidate, threaten, restrain, coerce, blacklist, or in any manner discriminate against,
any person who has with just cause:
(i) Filed a complaint under or related to Sec. 218 of the INA (8 U.S.C. 1188), or any Department regulation promulgated
under Sec. 218 of the INA;
(ii) Instituted or caused to be instituted any proceeding under or related to Sec. 218 of the INA, or any Department
regulation promulgated under Sec. 218 of the INA;
(iii) Testified or is about to testify in any proceeding under or related to Sec. 218 of the INA or any Department regulation
promulgated under Sec. 218 of the INA;
(iv) Consulted with an employee of a legal assistance program or an attorney on matters related to Sec. 218 of the INA
or any Department regulation promulgated under Sec. 218 of the INA; or
(v) Exercised or asserted on behalf of himself/herself or others any right or protection afforded by Sec. 218 of the INA, or
any Department regulation promulgated under Sec. 218 of the INA.
13. The employer has not and will not discharge any person because of that person's taking any action listed in paragraph 12(i) through
(v) listed above.
14. The employer will inform H-2A workers of the requirement that they leave the U.S. at the end of the period certified by the
Department or separation from the employer, whichever is earlier, as required under 20 CFR 655.135(i), unless the H-2A
worker is being sponsored by another subsequent employer.
15. The employer has posted the Notice of Workers’ Rights as required by 20 CFR 655.135(l) in a conspicuous place frequented
by all employees,
16. If the application is being filed as an H-2A Labor Contractor the following additional attestations and obligations apply under 20
CFR 655.132:
(i) The H-2A Labor Contractor has provided a copy of the MSPA Farm Labor Contractor (FLC) certificate of registration
if required under MSPA, 1801 U.S.C. et seq., to have such a certificate identifying the specific farm labor contracting
activities it is authorized to perform;
(ii) The H-2A Labor Contractor has provided with this application a list of the names and locations of each fixed-site
agricultural business to which the H-2A Labor Contractor expects to provide H-2A workers, the expected beginning
and ending dates when the H-2A Labor Contractor will be providing the workers to each fixed site, and a description
of the crops and activities the workers are expected to perform at such fixed site;
(iii) The H-2A Labor Contractor is able to provide proof of its ability to discharge financial obligations under the H-2A
program and has secured a surety bond as required by 29 CFR 501.9, the original of which is attached and shows
Form ETA-9142A – Appendix A TO BE COMPLETED BY EMPLOYER FROM A CERTIFIED FORM ETA-9142A

Page A.2 of A.3

Case Number:___________________ Case Status: __________________ Period of Employment: ______________ to _______________

OMB Approval: 1205-0466
Expiration Date: 5/31/2019

H-2A Application for Temporary Employment Certification
Form ETA-9142A – APPENDIX A
U.S. Department of Labor
the name, address, phone number, and contact person for the surety, and provides the amount of the bond (as
calculated pursuant to 29 CFR 501.9);
(iv) The H-2A Labor Contractor has engaged in and will engage in recruitment efforts in each area of intended
employment in which it has listed a fixed-site agricultural business as required in 20 CFR 655.121, 655.150-155 and
655.215; and
(v) The H-2A Labor Contractor has obtained from each fixed-site agricultural business that will provide housing or
transportation to the workers a written statement stating that:
a. All housing used by workers and owned, operated, or secured by the fixed-site agricultural business
complies with the applicable housing standards in 20 CFR 655.122(d) and, if applicable, 655.235; and
b. All transportation between the worksite and the workers' living quarters that is provided by the fixed-site
agricultural business complies with all applicable Federal, State, or local laws and regulations and will
provide, at a minimum, the same vehicle safety standards, driver licensure, and vehicle insurance as
required under 29 U.S.C. 1841 and 29 CFR part 500, except where workers’ compensation is used to
cover such transportation as described in § 655.122(e); and
c. Attach to the statement certificates of occupancy from the SWA for all employer owned housing and copies
of all drivers’ licenses, vehicle registration, and insurance policies for all drivers and vehicles used to
transport H-2A workers.
I hereby acknowledge that the agent or attorney identified in section E (if any) of the Form ETA-9142A and section A above is
authorized to represent me for the purpose of labor certification and, by virtue of my signature in Block 5 below, I take full
responsibility for the accuracy of any representations made by my agent or attorney.
I declare under penalty of perjury that I have read and reviewed this application and that to the best of my knowledge the information
contained therein is true and accurate. I understand that to knowingly furnish false information in the preparation of this form and any
supplement thereto or to aid, abet, or counsel another to do so is a felony punishable by a $250,000 fine or 5 years in the Federal
penitentiary or both (18 U.S.C. 1001).

1. Last (family) name

2. First (given) name

3. Middle initial

4. Title

5. Signature

6. Date signed

Public Burden Statement
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 1 hour to complete the form, including the time for reviewing instructions,
searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. 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 Office of Foreign Labor
Certification * U.S. Department of Labor * Box 12-200 * 200 Constitution Ave., NW, * Washington, DC * 20210. Please do not send the
completed application to this address.

Form ETA-9142A – Appendix A TO BE COMPLETED BY EMPLOYER FROM A CERTIFIED FORM ETA-9142A

Page A.3 of A.3

Case Number:___________________ Case Status: __________________ Period of Employment: ______________ to _______________