9142A - Appendix D - Track Changes

O MB Approval: 1205-0466

Expiration Date: XX/XX/XXXX

H-2A Application for Temporary Employment Certification

Form ETA-9142A – Appendix D

U.S. Department of Labor

Pursuant to 20 CFR 655.137(b), the employer, and its attorney or agent (as applicable), must provide the identity and location of all persons and entities hired by or working for the recruiter or agent, and any of the agent(s) or employee(s) of those persons and entities, to recruit prospective foreign workers for the H-2A job opportunities offered by the employer under this H-2A Application for Temporary Employment Certification, Form ETA-9142A. Please complete each section of “Foreign Labor Recruiter Information” below. If the employer has more than three (3) persons and entities to identify, the employer must disclose as many additional “Foreign Labor Recruiter Information” sections as are necessary to list all persons or entities engaged in foreign worker recruitment for this application.

Foreign Labor Recruiter Information 1

1. Recruiter’s Last (family) Name *	2. First (given) Name *		3. Middle Name(s) §
4. Name of Employer/Recruiting Organization *
5. City *		6. State *	7. Postal Code *
8. Country *		9. Province §
10. Registration Number 1	11. Issuing Country *
12. Registration Number 2	13. Issuing Country *
14. Registration Number 3	15. Issuing Country *

Foreign Labor Recruiter Information 2

1. Recruiter’s Last (family) Name *	2. First (given) Name *		3. Middle Name(s) §
4. Name of Employer/Recruiting Organization *
5. City *		6. State *	7. Postal Code *
8. Country *		9. Province §
10. Registration Number 1	11. Issuing Country *
12. Registration Number 2	13. Issuing Country *
14. Registration Number 3	15. Issuing Country *

Foreign Labor Recruiter Information 3

1. Recruiter’s Last (family) Name *	2. First (given) Name *		3. Middle Name(s) §
4. Name of Employer/Recruiting Organization *
5. City *		6. State *	7. Postal Code *
8. Country *		9. Province §
10. Registration Number 1	11. Issuing Country *
12. Registration Number 2	13. Issuing Country *
14. Registration Number 3	15. Issuing Country *

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

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

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