OMB Approval: 1205-0509
Expiration Date: 03/31/2016
H-2B Application for Temporary Employment Certification
ETA Form 9142B
U.S. Department of Labor
ETA Form 9142B FOR DEPARTMENT OF LABOR USE ONLY Page 6 of 6
Case Number: ______________________ Case Status: __________________ Validity Period: ______________ to _______________
I. Declaration of Employer and Attorney/Agent
In accordance with Federal regulations, the employer must attest that it will 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 or Appendix B will be
considered incomplete and not accepted for processing by the ETA application processing center.
1. For H-2A Applications ONLY, please confirm that you have read and agree to all the
applicable terms, assurances and obligations contained in Appendix A. §
Yes No N/A
2. For H-2B Applications ONLY, please confirm that you have read and agree to all the
applicable terms, assurances and obligations contained in Appendix B. §
Yes No N/A
J. 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
E (attorney or agent) of this application.
1. Last (family) name §
2. First (given) name §
3. Middle name
§
5. Firm/Business name §
§
K. U.S. Government Agency Use (ONLY)
Pursuant to the provisions of Section 101 (a)(15)(h)(ii) of the Immigration and Nationality Act, as amended, I hereby
certify that there are not sufficient U.S. workers available and the employment of the above will not adversely affect the
wages and working conditions of workers in the U.S. similarly employed. By virtue of the signature below, the
Department of Labor hereby acknowledges the following:
This certification is valid from _______________________ to ___________________________.
______________________________________________ ______________________________
Department of Labor, Office of Foreign Labor Certification Determination Date (date signed)
______________________________________________ ______________________________
Case number Case Status
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 1.5 hours to complete the form and 25 minutes per response for all other H-2B
information collection requirements, 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 * Room C4312 * 200
Constitution Ave., NW, * Washington, DC * 20210 or by email ETA.OFLC.Forms@dol.gov
. Please do not send the completed application
to this address.