ETA-790A - Addendu Additional Place of Employment Information

O MB Approval: 1205-0466

Expiration Date: XX/XX/XXXX

H-2A Agricultural Clearance Order

Form ETA-790A Addendum B

U.S. Department of Labor

C.1. Additional Agricultural Business Information

Ag Business 1

1. FEIN (from IRS) *	2. Legal Business Name *					3. Total Workers *
4. Trade Name/Doing Business As (DBA), if applicable §		5. Previous DBA, if applicable §			6. Previous DBA, if applicable §
7. Address 1 *					8. Address 2 (suite/floor and number) §
9. City *		10. State *	11. Postal code *	12. County *

Ag Business 2

1. FEIN (from IRS) *	2. Legal Business Name *					3. Total Workers *
4. Trade Name/Doing Business As (DBA), if applicable §		5. Previous DBA, if applicable §			6. Previous DBA, if applicable §
7. Address 1 *					8. Address 2 (suite/floor and number) §
9. City *		10. State *	11. Postal code *	12. County *

Ag Business 3

1. FEIN (from IRS) *	2. Legal Business Name *					3. Total Workers *
4. Trade Name/Doing Business As (DBA), if applicable §		5. Previous DBA, if applicable §			6. Previous DBA, if applicable §
7. Address 1 *					8. Address 2 (suite/floor and number) §
9. City *		10. State *	11. Postal code *	12. County *

C.2. Additional Place of Employment Information

1. Legal Business Name *	2. Place of Employment *			3. Additional Place of Employment Information and Crop and Agricultural Activity *	4. Begin Date §	5. End Date §
	Address Location *
	City *		State*
	Postal Code *	County *
	Address Location *
	City *		State*
	Postal Code *	County *
	Address Location *
	City *		State*
	Postal Code *	County *
	Address Location *
	City *		State*
	Postal Code *	County *
	Address Location *
	City *		State*
	Postal Code *	County *

D. Additional Housing Information

1. Type of Housing *	2. Physical Location *			3. Additional Housing Information §	4. Total Units *	5. Total Occupancy *	6. Inspection Entity *
 Employer-provided  Rental or public accommodations	Address Location *						 Local authority  SWA  Other State authority  Federal authority  Other _______________
	b. City *		c. State *
	d. Postal Code *	e. County *
 Employer-provided  Rental or public accommodations	Address Location *						 Local authority  SWA  Other State authority  Federal authority  Other _______________
	b. City *		c. State *
	d. Postal Code *	e. Postal Code *
 Employer-provided  Rental or public accommodations	Address Location *						 Local authority  SWA  Other State authority  Federal authority  Other _______________
	b. City *		c. State *
	d. Postal Code *	e. Postal Code *
 Employer-provided  Rental or public accommodations	Address Location *						 Local authority  SWA  Other State authority  Federal authority  Other _______________
	b. City *		c. State *
	d. Postal Code *	e. Postal Code *
 Employer-provided  Rental or public accommodations	Address Location *						 Local authority  SWA  Other State authority  Federal authority  Other _______________
	b. City *		c. State *
	d. Postal Code *	e. Postal Code *

For Public Burden Statement, see the Instructions for Form ETA-790/790A.

Form ETA-790A Addendum B FOR DEPARTMENT OF LABOR USE ONLY Page B.1 of B.3

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