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 owners of the agricultural business, the operators of each place of employment (if different than the employer(s)), and all persons who manage or supervise any worker employed under the job order associated with this application, regardless of whether those managers or supervisors are employed by the employer or another entity. Please complete each section of “Additional Contact Information” below. If more than three (3) persons need to be identified, the employer must disclose as many “Additional Contact Information” sections as necessary to provide a complete response.

Additional Contact Information 1

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

Additional Contact Information 2

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

Additional Contact Information 3

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