OMB Approval: 1205-0466 Expiration Date: 05/31/2019 H-2A Application for Temporary Employment Certification Form ETA-9142A U.S. Department of Labor Please read and review the filing instructions carefully before completing the Form ETA-9142A. A copy of the instructions can be found at http://www.foreignlaborcert.doleta.gov/. In accordance with Federal Regulations, incomplete or obviously inaccurate applications will not be certified by the Department of Labor. If submitting this form non-electronically, ALL required fields/items containing an asterisk ( * ) must be completed as well as any fields/items where a response is conditional as indicated by the section ( § ) symbol. A. Employment-Based Nonimmigrant Visa Information 1. Indicate the type of visa classification supported by this application (Write classification symbol): * B. Temporary Need Information 1. Job Title * 2. SOC (ONET/OES) code * 3. SOC (ONET/OES) occupation title * 4. Is this a full-time position? * Yes No 5. Begin Date * (mm/dd/yyyy) Period of Intended Employment 6. End Date * (mm/dd/yyyy) 7. Worker positions needed/basis for the visa classification supported by this application Total Worker Positions Being Requested for Certification * Basis for the visa classification supported by this application (indicate the total workers in each applicable category based on the total workers identified above) a. New employment * b. Continuation of previously approved employment * without change with the same employer c. Change in previously approved employment * 8. Nature of Temporary Need: (Choose only one of the standards) * Seasonal Peakload One-Time Occurrence Intermittent or Other Temporary Need d. New concurrent employment * e. Change in employer * f. Amended petition * 9. Statement of Temporary Need * Form ETA-9142A FOR DEPARTMENT OF LABOR USE ONLY Case Status: __________________ Page 1 of 6 Case Number: ______________________ Validity Period: ______________ to _______________ American LegalNet, Inc. www.FormsWorkFlow.com OMB Approval: 1205-0466 Expiration Date: 05/31/2019 H-2A Application for Temporary Employment Certification Form ETA-9142A U.S. Department of Labor C. Employer Information Important Note: Enter the full name of the individual employer, partnership, or corporation and all other required information in this section. For joint employer or master applications filed on behalf of more than one employer under the H-2A program, identify the main or primary employer in the section below and then submit a separate attachment that identifies each employer, by name, mailing address, and total worker positions needed, under the application. 1. Legal business name * 2. Trade name/Doing Business As (DBA), if applicable 3. Address 1 * 4. Address 2 5. City * 8. Country * 10. Telephone number * 12. Federal Employer Identification Number (FEIN from IRS) * 14. Number of non-family full-time equivalent employees 6. State * 9. Province 11. Extension 13. NAICS code (must be at least 4-digits) * 15. Annual gross revenue 16. Year established 7. Postal code * 17. Type of employer application (choose only one box below) * Individual Employer H-2A Labor Contractor or Job Contractor Association ­ Sole Employer (H-2A only) Association ­ Joint Employer (H-2A only) Association ­ Filing as Agent (H-2A only) D. Employer Point of Contact Information Important Note: The information contained in this Section must be that of an employee of the employer who is authorized to act on behalf of the employer in labor certification matters. The information in this Section must be different from the agent or attorney information listed in Section E, unless the attorney is an employee of the employer. For joint employer or master applications filed on behalf of more than one employer under the H-2A program, enter only the contact information for the main or primary employer (e.g., contact for an association filing as joint employer) under the application. 1. Contact's last (family) name * 4. Contact's job title * 5. Address 1 * 6. Address 2 7. City * 10. Country * 12. Telephone number * 2. First (given) name 3. Middle name(s) 8. State * 11. Province 13. Extension 14. E-Mail address 9. Postal code * Form ETA-9142A FOR DEPARTMENT OF LABOR USE ONLY Case Status: __________________ Page 2 of 6 Case Number: ______________________ Validity Period: ______________ to _______________ American LegalNet, Inc. www.FormsWorkFlow.com OMB Approval: 1205-0466 Expiration Date: 05/31/2019 H-2A Application for Temporary Employment Certification Form ETA-9142A U.S. Department of Labor E. Attorney or Agent Information (If applicable) 1. Is/are the employer(s) represented by an attorney or agent in the filing of this application Yes (including associations acting as agent under the H-2A program)? If "Yes", complete Section E. * 3. First (given) name § 4. Middle name 2. Attorney or Agent's last (family) name § No 5. Address 1 § 6. Address 2 7. City § 10. Country § 12. Telephone number § 13. Extension 8. State 11. Province 14. E-Mail address 9. Postal code § 15. Law firm/Business name § 17. State Bar number (only if attorney) § 16. Law firm/Business FEIN § 18. State of highest court where attorney is in good standing (only if attorney) § 19. Name of the highest court where attorney is in good standing (only if attorney) § F. Job Offer Information a. Job Description 1. Job Title * 2. Number of hours of work per week Basic *: _______ Overtime: _______ 3. Hourly Work Schedule * A.M. (h:mm): ___ : ____ P.M. (h:mm): ___ : ____ 4a. If yes, number of employees worker will supervise (if applicable) § ______ 4. Does this position supervise the work of other employees? * Yes No 5. Job duties ­ A description of the duties to be performed MUST begin in this space. If necessary, add attachment to continue and complete description. * Form ETA-9142A FOR DEPARTMENT OF LABOR USE ONLY Case Status: __________________ Page 3 of 6 Case Number: ______________________ Validity Period: ______________ to _______________ American LegalNet, Inc. www.FormsWorkFlow.com OMB Approval: 1205-0466 Expiration Date: 05/31/2019 H-2A Application for Temporary Employment Certification Form ETA-9142A U.S. Department of Labor F. Job Offer Information (continued) b. Minimum Job Requirements 1. Education: minimum U.S. diploma/degree required * None High School/GED Associate's Bachelor's Master's Doctorate (PhD) Other degree (JD, MD, etc.) 1a. If "Other degree" in question 1, specify the diploma/ 1b. Indi