ETA-9142A – Append Owners-Managers Form

O MB Approval: 1205-0466

Expiration Date: XX/XX/XXXX

H-2A Application for Temporary Employment Certification

Form ETA-9142A – Appendix C

U.S. Department of Labor

Each employer, and any joint employer identified on the job order (Form ETA-790/790A), must provide the identity, location, and contact information of all persons who are the owners of the agricultural business, all persons who are the operators of each place of employment (if different than the owners), and all persons hired by or working for the employer and joint employer(s) as a manager or supervisor of any worker employed under this application. Please complete each section of “Employer/Joint Employer Contact Information” below. If more than three (3) persons need to be identified, the employer must disclose as many additional “Employer/Joint Employer Contact Information” sections as are necessary to list all persons under this application.

Additional Contact Information 1

1. Ag Business ID *	2. Role of person (select all that apply) §  Owner – Employer  Operator of Place of Employment  Manager  Supervisor
3. FEIN (from IRS) *	4. Legal Business Name *
5. Contact’s Last (family) Name *		6. First (given) Name *			7. Middle Name(s) §
8. Address 1 *					9. Address 2 (apt/suite/floor and number) §
10. City *		11. State *	12. Postal Code *		13. County *
14. Country *			15. Province §
16. Date of Birth*		17. Telephone Number*	18. Extension §	Email Address *

Additional Contact Information 2

1. Ag Business ID *	2. Role of person (select all that apply) §  Owner – Employer  Operator of Place of Employment  Manager  Supervisor
3. FEIN (from IRS) *	4. Legal Business Name *
5. Contact’s Last (family) Name *			6. First (given) Name *				7. Middle Name(s) §
8. Address 1 *							9. Address 2 (apt/suite/floor and number) §
10. City *			11. State *		12. Postal Code *		13. County *
14. Country *					15. Province §
16. Date of Birth*		17. Telephone Number*		18. Extension §		Email Address *

Additional Contact Information 3

1. Ag Business ID *	2. Role of person (select all that apply) §  Owner – Employer  Operator of Place of Employment  Manager  Supervisor
3. FEIN (from IRS) *	4. Legal Business Name *
5. Contact’s Last (family) Name *			6. First (given) Name *				7. Middle Name(s) §
8. Address 1 *							9. Address 2 (apt/suite/floor and number) §
10. City *			11. State *		12. Postal Code *		13. County *
14. Country *					15. Province §
16. Date of Birth*		17. Telephone Number*		18. Extension §		Email Address *

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

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

H-2A Case Number: __________________ Case Status: __________________ Determination Date: _____________ Validity Period: _____________ to _____________