Fillable Form ETA-9142A: Association Sole Employer Association - Joint (Department of Labor)

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Form ETA-9142A: Association Sole Employer Association - Joint (Department of Labor)

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OMB Approval: 1205-0466
Expiration Date: 08/31/2022
H-2A Application for Temporary Employment Certification
Form ETA-9142A
U.S. Department of Labor
Form ETA-9142A FOR DEPARTMENT OF LABOR USE ONLY Page 1 of 3
H-2A Case Number: __________________ Case Status: __________________ Determination D
ate: _____________ Validity Period: _____________ to _____________
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 at http://www.foreignlaborcert.doleta.gov/
. 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)
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. Is a statement justifying the employer’s emergency situation attached to this application? *
Yes No N/A
B. 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 *
7. Postal Code *
8. Country *
9. Province
§
10. Telephone Number *
11. Extension
§
(FEIN from IRS)
13. NAICS Code
*
C. Employer Point of Contact Information
The information contained in this Section must be that of an employee of the employer who is authorized to act on behalf of the employer in labor certification matters.
The information in this Section must be different from the agent or attorney information listed in Section D, unless the attorney is an employee of the employer.
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 *
OMB Approval: 1205-0466
Expiration Date: 08/31/2022
H-2A Application for Temporary Employment Certification
Form ETA-9142A
U.S. Department of Labor
Form ETA-9142A FOR DEPARTMENT OF LABOR USE ONLY Page 2 of 3
H-2A Case Number: __________________ Case Status: __________________ Determinatio
n Date: _____________ Validity Period: _____________ to _____________
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)
§
8. State §
9. Postal Code §
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 to 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. Is a copy of the current agreement or other documentation demonstrating the agent’s authority
to represent the employer in this application attached? §
Yes No
21. Is 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 attached to this application? §
Yes No N/A
E. Job Opportunity & Supporting Documentation
1. SOC Occupational Code *
2. SOC Occupation Title *
3. Is a copy of the completed job order (Form ETA-790/790A) satisfying the requirements at
20 CFR 653, subpart F, and 20 CFR 655.122 attached to this application? *
Yes No
4. If “Joint Employer” or “Association – Joint Employer” i
s marked in question A.1, does the
Form ETA-790A identify the name, address, total number of workers needed, and crops and
agricultural work of each employer that will employ
wor
kers?
§
Yes No
For H-2A Labor Contractors ONLY
If “Yes” is marked in question A.2, complete questions E.5 through E.9 below
5. Does the Form ETA-
790A identify the name(s) and location(s) of each fixed-site agricultural
business the employer will be providing H-2A workers, the expected beginning and end dates,
and a description of crops and activities the workers will perform? §
Yes No
6. Is a copy of fully-executed work contract(s) with each fixed-site agricultural business identified
on the Form ETA-790A attached to this application? §
Yes No
7. Is a copy of the employer’s current MSPA Certificate of Registration identifying the farm labor
contracting activities the employer is authorized to perform attached to this application?
§
Yes No N/A
8. Is a surety bond meeting the requirements of 20 CFR 655.132(b)(3) attached to this application?§
Yes No
9. Will any of the fixed-site agricultural businesses provide workers with housing and/or
transportation between the worksite and the living quarters under this application?
§
Yes No
OMB Approval: 1205-0466
Expiration Date: 08/31/2022
H-2A Application for Temporary Employment Certification
Form ETA-9142A
U.S. Department of Labor
Form ETA-9142A FOR DEPARTMENT OF LABOR USE ONLY Page 3 of 3
H-2A Case Number: __________________ Case Status: __________________ Determinat
ion Date: _____________ Validity Period: _____________ to _____________
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 not be certified by the Department.
1. Please confirm that you have read and agree to all the applicable terms, assurances, and
obligations contained in Appendix A and have attached a signed and dated copy of Appendix A
with this application. *
Yes No
2. Except for agricultural associations filing as a joint employer, please confirm that each employer
filing as a joint employer on the job order (Form ETA-790/790A) has read and agree to all the
applicable terms, assurances and obligations contained in Appendix A and has attached a
separate signed and dated copy of Appendix A with this application. *
Yes No 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
§
Public Burden Statement (1205-0466)
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 3.66 hours per response for all H-2A information collection requirements, including the time for reviewing instructions, searching
existing data sources, gathering and maintaining the data needed, and completing, reviewing, and submitting 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.). Send comments regarding this burden estimate or
any other aspect of this collection of information, including suggestions for reducing this burden, to the U.S. Department of Labor, Employment and Training
Administration, Office of Foreign Labor Certification, 200 Constitution Ave., NW, Suite PPII 12-200, Washington, DC, 20210. (Paperwork Reduction Project OMB 1205-
0466). DO NOT send the completed application to this address.
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Form ETA-9142A: Association Sole Employer Association - Joint (Department of Labor)

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Completed 26 January 2021

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