ETA-790B, Addendum Non-Criteria Agricultural Clearance Order

O MB Approval: 1205-0134

Expiration Date: XX/XX/XXXX

Non-Criteria Agricultural Clearance Order

Form ETA-790B Addendum B

U.S. Department of Labor

C. Additional Agricultural Business Information

Ag Business 1

1. FEIN (from IRS) *	2. Legal Business Name *
3. Trade Name/Doing Business As (DBA), if applicable §	4. Previous DBA, if applicable §			5. Previous DBA, if applicable §
6. Address 1 *				7. Address 2 (suite/floor and number) §
8. City *	9. State *	10. Postal code *	11. County *

Ag Business 2

1. FEIN (from IRS) *	2. Legal Business Name *
3. Trade Name/Doing Business As (DBA), if applicable §	4. Previous DBA, if applicable §			5. Previous DBA, if applicable §
6. Address 1 *				7. Address 2 (suite/floor and number) §
8. City *	9. State *	10. Postal code *	11. County *

Ag Business 3

1. FEIN (from IRS) *	2. Legal Business Name *
3. Trade Name/Doing Business As (DBA), if applicable §	4. Previous DBA, if applicable §			5. Previous DBA, if applicable §
6. Address 1 *				7. Address 2 (suite/floor and number) §
8. City *	9. State *	10. Postal code *	11. County *

D. Additional Place of Employment Information

1. Place of Employment *			2. Additional Place of Employment Information and crop and agricultural activity *	3. Begin Date §	4. End Date §	5. 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 *
 Employer-provided  Rental or public accommodations
 Employer-provided  Rental or public accommodations
 Employer-provided  Rental or public accommodations
 Employer-provided  Rental or public accommodations
 Employer-provided  Rental or public accommodations

For Public Burden Statement, see the Instructions for Form ETA-790B.

Form ETA-790B Addendum FOR STATEWORKFORCE AGENCY USE ONLY Page B.3 of B.3

Clearance Order Number: _______________________