Form ETA-790A Adde 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. Additional Agricultural Business Information

Ag Business 1

1. Ag Business ID *	2. FEIN (from IRS) *	3. Legal Business Name *
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. Ag Business ID *	2. FEIN (from IRS) *	3. Legal Business Name *
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. Ag Business ID *	2. FEIN (from IRS) *	3. Legal Business Name *
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 *

D. Additional Place of Employment Information

1. Ag Business ID *	2. Place of Employment *			3. Additional Place of Employment Information §	4. Begin Date §	5. End Date §	6. Total Workers §
	Address 1
	Address 2 (suite/floor and number) §
	City		State
	Postal Code	County
	Address 1
	Address 2 (suite/floor and number) §
	City		State
	Postal Code	County
	Address 1
	Address 2 (suite/floor and number) §
	c. City		d. State
	e. Postal Code	f. County
	Address 1
	Address 2 (suite/floor and number) §
	c. City		d. State
	e. Postal Code	f. County
	Address 1
	Address 2 (suite/floor and number) §
	c. City		d. State
	e. Postal Code	f. County

E. 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					 Local authority  SWA  Other State authority  Federal authority  Other _______________
 Employer-provided  Rental or public accommodations					 Local authority  SWA  Other State authority  Federal authority  Other _______________
 Employer-provided  Rental or public accommodations					 Local authority  SWA  Other State authority  Federal authority  Other _______________
 Employer-provided  Rental or public accommodations					 Local authority  SWA  Other State authority  Federal authority  Other _______________
 Employer-provided  Rental or public accommodations					 Local authority  SWA  Other State authority  Federal authority  Other _______________

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 _____________