Fillable Form ETA-9142B: H-2B Application for Temporary Employment Certification (Department of Labor)

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Form ETA-9142B: H-2B Application for Temporary Employment Certification (Department of Labor)

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The Form ETA-9142B: H-2B Application for Temporary Employment Certification (Department of Labor) form is 5 pages long and contains:

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1. Is the employer seeking to employ any H-2B workers under this application who will be exempt
from the statutory numerical limit, or “cap,” on the total number of foreign nationals who may
be issued an H-2B visa or otherwise granted H-2B status? *
OMB Approval: 1205-0509
Expiration Date: 05/31/2022
H-2B Application for Temporary Employment Certification
Form ETA-9142B
U.S. Department of Labor
IMPORTANT: Employers and authorized preparers must read the general instructions carefully before completing the Form ETA-9142B. A copy of the instructions
can be found at http://www.foreignlaborcert.doleta.gov/. If you are not submitting this 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-2B Application
Yes No
B. Temporary Need Information
1. Job Title *
2. SOC Code *
3. SOC Occupation Title *
4. Number of
Workers *
5. Begin Date *
(mm/dd/yyyy)
6. End Date *
(mm/dd/yyyy)
7. Nature of Temporary Need
(Choose only one)
*
Seasonal Peakload One-Time Occurrence Intermittent
8. Statement of Temporary Need *
(Must be disclosed on this form. One separate attachment will be accepted to fully complete the response.)
C. 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 *
7. Postal Code *
8. Country *
9. Province §
10. Telephone Number *
11. Extension §
12. Federal Employer Identification Number
(FEIN from IRS)
*
13. NAICS Code *
Form ETA-9142B FOR DEPARTMENT OF LABOR USE ONLY Page 1 of 5
H-2B Case Number: __________________ Case Status: __________________ Determination Date: _____________ Validity Period: _____________ to _____________
OMB Approval: 1205-0509
Expiration Date: 05/31/2022
H-2B Application for Temporary Employment Certification
Form ETA-9142B
U.S. Department of Labor
D. 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 E, 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 *
E. 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 E.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 E.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
Form ETA-9142B FOR DEPARTMENT OF LABOR USE ONLY Page 2 of 5
H-2B Case Number: __________________ Case Status: __________________ Determination Date: _____________ Validity Period: _____________ to _____________
F. Employment and Wage Information
a. Job Opportunity and Minimum Requirements
OMB Approval: 1205-0509
Expiration Date: 05/31/2022
H-2B Application for Temporary Employment Certification
Form ETA-9142B
U.S. Department of Labor
1. Indicate whether a copy of the job order submitted to the State Workforce Agency (SWA)
satisfying the requirements at 20 CFR 655.18 is attached to this application. *
Yes No
2. Name of the State *
3. Date Job Order
Submitted *
4. Job Duties – Description of the specific services or labor to be performed. *
(All job duties must be disclosed on this form. One separate attachment will be accepted to fully complete the response.)
5. Anticipated days and hours of work per week (an entry is required for each box below) * 6. Hourly work schedule *
a. Total Hours
c. Monday e. Wednesday g. Friday
a. _____ : _____
AM
PM
b. Sunday d. Tuesday f. Thursday h. Saturday
b. _____ : _____
AM
PM
7. Education: minimum U.S. diploma/degree required. *
None High School/GED Associate’s Bachelor’s Master's Doctorate (PhD) Other degree (JD, MD,
etc.)
8. Training: number of months required. *
9. Work Experience: number of months required. *
10. Supervision: does this position supervise
the work of other employees? *
Yes No
10a. If “Yes” to question 10, enter the number
of employees worker will supervise.
§
11. Special Requirements - List specific skills, licenses/certifications, field(s) of training, and requirements of the job. *
Form ETA-9142B FOR DEPARTMENT OF LABOR USE ONLY Page 3 of 5
H-2B Case Number: __________________ Case Status: __________________ Determination Date: _____________ Validity Period: _____________ to _____________
OMB Approval: 1205-0509
Expiration Date: 05/31/2022
H-2B Application for Temporary Employment Certification
Form ETA-9142B
U.S. Department of Labor
b. Place of Employment and Wage Information
1. Worksite Address *
2. Worksite Address §
(apartment/suite/floor and number)
3. City *
5. Postal Code *
6. County *
7. Metropolitan Statistical Area (MSA) Name/OES Area Title *
8. Basic Wage Rate Paid *
From:
$ ______ . ____
*
To:
$ ______ . ____
8a. Overtime Wage Rate Paid
§
From:
$ ______ . ____
To:
$ ______ . ____
9. Per (Choose only one) *
Hour Week Bi-
Weekly
Month Year Piece Rate
9a. Additional conditions about the wage rate to be paid. §
DOL Prevailing Wage Determination (PWD) Information
10. 1st PWD Case Number *
10a. 2nd PWD Case Number
§
10b. 3rd PWD Case Number
§
11. If a valid PWD has not been obtained due to an emergency situation under 20 CFR 655.17,
indicate whether a completed Form ETA-9141 is attached to this application.
§
Yes No N/A
c. Additional Place of Employment and Wage Information
1. Will work be performed at worksite locations other than the one identified in Section F.b.? *
Yes
2. If “Yes” is marked in question F.c.1, indicate whether a completed Appendix A is attached to
this application. §
Yes No
d. Other Material Terms and Conditions of the Job Offer
1. Daily Transportation: Workers will be provided with daily transportation to and from the
worksite in compliance with all applicable Federal, State and local laws and regulations. *
Yes N/A
2. Overtime Available: Overtime hours will be available to the workers and payable at the rate
disclosed in Section F.b.8a of this application. *
Yes N/A
3. On-the-Job Training Available: Workers will be provided with on-the-job training to perform
the duties assigned. *
Yes N/A
4.
Employer-Provided Tools and Equipment:
Workers will be provided, without charge or
deposit charge, all tools, supplies, and equipment required to perform the duties assigned.
*
Yes N/A
5. Board, Lodging, or Other Facilities: Workers will be provided with board, lodging, or other
facilities and/or the employer will assist workers in securing board, lodging, or other facilities. *
Yes N/A
6. Deductions From Pay: State all deduction(s) from pay and, if known, the amount(s). *
e. Recruitment Information
1. Telephone Number to Apply *
2. Email Address to Apply *
3. Website address (URL) to Apply *
Form ETA-9142B FOR DEPARTMENT OF LABOR USE ONLY Page 4 of 5
H-2B Case Number: __________________ Case Status: __________________ Determination Date: _____________ Validity Period: _____________ to _____________
OMB Approval: 1205-0509
Expiration Date: 05/31/2022
H-2B Application for Temporary Employment Certification
Form ETA-9142B
U.S. Department of Labor
G. Other Supporting Documentation
1. Type of Employer Application (Choose only one) *
Individual Employer Job Contractor – Joint Employer
2. 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
If “Job Contractor – Joint Employer” is marked in question G.1, complete questions 3 and 4 below.
3. Indicate whether a completed Appendix D identifying the employer-client has been completed. §
Yes No
4. Indicate whether an executed contract or other agreement exists between the job contractor and
the employer-client establishing a bona fide relationship to the workers sought under this
application. §
Yes No
Foreign Labor Recruiter Information
5. 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-2B workers, regardless of whether
such agent(s) or recruiter(s) is (are) located in the U.S. or abroad? *
Yes No
6. 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-2B workers is attached to this application. *
Yes No N/A
7. Indicate whether a completed Appendix C 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 No N/A
H. 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 B 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 B and have attached a signed and dated copy of Appendix B
with this application. *
Yes No
2. Please confirm that the employer-client identified in Appendix D has read and agrees to all the
applicable terms, assurances, and obligations contained in Appendix B and has attached a
separate signed and dated copy of Appendix B with this application. *
Yes No N/A
I. Preparer
Complete this section if the preparer of this application is a person other than the one identified in either Section D (employer point of contact) or Section E (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. Law Firm/Business Email Address §
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 ETA.OFLC.Forms@dol.gov
. Please do not send the
completed application to this address.
Form ETA-9142B FOR DEPARTMENT OF LABOR USE ONLY Page 5 of 5
H-2B Case Number: __________________ Case Status: __________________ Determination Date: _____________ Validity Period: _____________ to _____________
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Form ETA-9142B: H-2B Application for Temporary Employment Certification (Department of Labor)

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Completed 26 January 2021

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