ETA-9142C Appendix A

O MB Approval: 1205-0534

Expiration Date: 10/31/2021

CW-1 Application for Temporary Employment Certification

Form ETA-9142C – Appendix A

U.S. Department of Labor

A job contractor means a person, association, firm, or a corporation that meets the definition of an employer and that contracts services or labor on a temporary basis to one or more employers that are not an affiliate, branch, or subsidiary of the job contractor and where the job contractor will not exercise substantial, direct day-to-day supervision and control in the performance of the services or labor to be performed other than hiring, paying, and firing the workers. 20 CFR 655.402, 655.421. Pursuant to 20 CFR 655.421(a), a job contractor may only submit a CW-1 Application for Temporary Employment Certification, Form ETA-9142C, if it is filing as a joint employer with its employer-client. An employer-client means an employer that has entered into an agreement with a job contractor, as defined in 20 CFR 655.402. Pursuant to 20 CFR 655.421(d)(1), a job contractor that is filing as a joint employer with its employer-client must submit a completed CW-1 Application for Temporary Employment Certification, Form ETA-9142C, that clearly identifies the joint employers (the job contractor and its employer-client) and the employment relationship (including the actual place(s) of employment disclosed on the Form ETA-9142C). Please complete Sections A and B below and attach this form to the Form ETA-9142C that will be submitted to the Department for processing.

1. Employer-Client 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 §
12. Federal Employer Identification Number (FEIN from IRS) *	13. NAICS Code *

B. Employer-Client 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 *

For the public burden statement, please see the Form ETA-9142C, General Instructions.

Form ETA-9142C, Appendix A FOR DEPARTMENT OF LABOR USE ONLY Page A.1 of A.2

CW-1 Case Number: __________________ Case Status: __________________ Determination Date: _____________ Validity Period: _____________ to ____________