Form ETA-9142A Form ETA-9142A Nature of H-2A Application

O MB Approval: 1205-0466

Expiration Date: XX/XX/XXXX

H-2A Application for Temporary Employment Certification

Form ETA-9142A

U.S. Department of Labor

IMPORTANT: Employers and authorized preparers must read the general instructions carefully before completing the Forms ETA-9142A and ETA-790/790A. A copy of the instructions can be found on the Office of Foreign Labor Certification website at https://www.dol.gov/agencies/eta/foreign-labor/forms. If you are not submitting these forms electronically, please complete ALL required fields/items containing an asterisk ( * ) and any fields/items where a response is conditional as indicated by the section ( § ) symbol.

A. Nature of H-2A Application

1. Type of Employer Application (choose only one)*  Individual Employer  Joint Employer (2 or more individual employers)
1a. Agricultural Association Employer or Agency Status, if applicable (choose only one) §  Association – Sole Employer  Association - Joint Employer  Association – Agent
2. Is the employer operating as an H-2A Labor Contractor (H-2ALC), as defined by 20 CFR 655.103(b)? *		 Yes  No
3. Nature of Temporary Need (choose only one) *	 Seasonal  Other Temporary Need
4. Is a statement of temporary need attached to this application? *		 Yes  No
5. Is this application being filed with a request to waive the regulatory time period due to an emergency situation, as defined by 20 CFR 655.134? *		 Yes  No
6. If “Yes” is marked in question A.5, a statement justifying the employer’s emergency situation is attached to this application. *		 Yes  N/A

B. Employer Information

1. Legal Business Name *
2. Trade Name/Doing Business As (DBA), if applicable §
3. Previous DBA, if applicable §	4. Previous DBA, if applicable §
5. Address 1 *
6. Address 2 (apartment/suite/floor and number) §
7. City *		8. State *	9. Postal Code *
10. Country *		11. Province §
12. Telephone Number *		13. Extension §
14. Federal Employer Identification Number (FEIN from IRS) *		15. NAICS Code *

C. 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 *	9. Postal Code *
10. Country *				11. Province §
12. Telephone Number *	13. Extension §		14. Business Email Address *

D. Attorney or Agent Information (If applicable)

1. Indicate the type of representation for the employer in the filing of this application. * Complete the remainder of this section if “Attorney” or “Agent” is marked.							 Attorney  Agent  None
2. Attorney or Agent’s Last (family) Name §		3. First (given) Name §					4. Middle Name(s) §
5. Address 1 §
6. Address 2 (apartment/suite/floor and number) §
7. City §					8. State §			9. Postal Code
10. Country §					11. Province §
12. Telephone Number §	13. Extension §		14. Law Firm/Business Email Address §
15. Law Firm/Business Name §						16. Law Firm/Business FEIN §
If “Attorney” is marked in question D.1, complete questions 17 – 19 below.
17. State Bar Number(s) §				18. State of highest court where attorney is in good standing §
19. Name of the highest state court where attorney is in good standing §
If “Agent” is marked in question D.1, complete questions 20 and 21 below.
20. A copy of the current agreement or other documentation demonstrating the agent’s authority to represent the employer in this application is attached to this application. §									 Yes
21. A copy of the agent’s current Migrant and Seasonal Agricultural Worker Protection Act (MSPA) Certificate of Registration identifying the farm labor contracting activities the agent is authorized to perform is attached to this application. §									 Yes  N/A

E. Job Opportunity & Supporting Documentation

1. SOC Occupational Code *		2. SOC Occupational Title *
3. A copy of the completed job order (Form ETA-790/790A) satisfying the requirements at 20 CFR 653, subpart F, and 20 CFR 655, subpart B, is attached to this application. *			 Yes
4. A completed Appendix C identifying all the owners of each employer and joint employer, operators of each place of employment (if different than the owner), and all the managers and supervisors of any worker employed under this application is attached to this application. *			 Yes
5. If “Joint Employer” is marked in question A.1, the Form ETA-790A and Addendum B identify the name(s), address(es), total number of workers needed, and crops and agricultural work of each employer that will employ workers. §			 Yes  N/A
For H-2A Labor Contractors ONLY If “Yes” is marked in question A.2, complete questions E.6 through E.10 below
6. The Form ETA-790A, Addendum B, identifies the name(s) and location(s) of each fixed-site agricultural business the employer will be providing H-2A workers, the expected first and last dates of work for each business, and a description of crops and activities the workers will perform. §			 Yes q No
7. A copy of fully-executed work contract(s) with each fixed-site agricultural business identified on the Form ETA-790A, Addendum B, is attached to this application. §			 Yes q No
8. A copy of the employer’s valid MSPA Certificate of Registration identifying the farm labor contracting activities the employer is authorized to perform is attached to this application. §			 Yes q No  N/A
9. A signed and dated Appendix B, H-2A Labor Contractor Surety Bond, for the employer identified in Section B of this application is attached. §			 Yes q No
10. Will any of the fixed-site agricultural businesses provide workers with housing and/or transportation between the place of employment and the living quarters under this application? §			 Yes  No
	Foreign Labor Recruiter Information
	11. Is the employer, and its attorney or agent, as applicable, engaging or planning to engage any agent(s) or recruiter(s) in the recruitment of prospective H-2A workers, regardless of whether such agent(s) or recruiter(s) is (are) located in the U.S. or abroad? *			 Yes q No
	11a. Indicate whether a copy of all agreements with any agent or recruiter whom you are engaging or planning to engage in the recruitment of H-2A workers is attached to this application. *			 Yes  N/A
	11b. Indicate whether a completed Appendix D providing the identity and location of all persons and entities hired by or working for the agent or recruiter subject to the agreement(s), including any of the agents or employees of those persons and entities, is attached to this application. *			 Yes  N/A

F. Declaration of Employer and Attorney/Agent

In accordance with Federal regulations, the employer(s) must attest to abide by certain terms, assurances, and obligations as a condition for receiving a temporary labor certification from the U.S. Department of Labor. Applications that fail to attach Appendix A will be considered incomplete and rejected without further review.

1. A signed and dated Appendix A for the employer identified in Section B of this application is attached. *	 Yes
2. Except for agricultural associations filing as a joint employer, a separate signed and dated Appendix A for each employer identified as a joint employer on the job order (Form ETA-790/790A) is attached. *	 Yes  N/A

G. Preparer

Complete this section if the preparer of this application is a person other than the one identified in either Section C (employer point of contact) or D (attorney or agent) of this application.

1. Last (family) Name §		2. First (given) Name §	3. Middle Initial §
4. Law Firm/Business FEIN §	5. Law Firm/Business Name §
6. Business Email Address §

For Public Burden Statement, see the Instructions for Form ETA-9142A.

Form ETA-9142A FOR DEPARTMENT OF LABOR USE ONLY Page 1 of 4

H-2A Case Number: __________________ Case Status: __________________ Determination Date: _____________ Validity Period: _____________ to _____________