DOL OFLC, Form ETA-9142C, Appendix A - Employer-Client Information

OMB Approval: 1205-0534 Expiration Date: 04/30/2026 CW-1 Application for Temporary Employment Certification Form ETA-9142C – Appendix A U.S. Department of Labor A job contractor means a person, association, firm, or a corporation that meets the definition of an employer and that contracts services or labor on a temporary basis to one or more employers that are not an affiliate, branch, or subsidiary of the job contractor and where the job contractor will not exercise substantial, direct day-to-day supervision and control in the performance of the services or labor to be performed other than hiring, paying, and firing the workers. 20 CFR 655.402, 655.421. Pursuant to .421(a), a job contractor may only submit a CW-1 Application for Temporary Employment Certification, Form ETA-9142C, if it is filing as a joint employer with its employer-client. An employer-client means an employer that has entered into an agreement with a job contractor, as defined in .402.

Pursuant to .421(d)(1), a job contractor that is filing as a joint employer with its employer-client must submit a completed CW-1 Application for Temporary Employment Certification, Form ETA-9142C, that clearly identifies the joint employers (the job contractor and its employer-client) and the employment relationship (including the actual place(s) of employment disclosed on the Form ETA-9142C). Please complete Sections A and B below and attach this form to the Form ETA-9142C that will be submitted to the Department for processing.

A. Employer-Client Information 1.

Legal Business Name * 2. Trade Name/Doing Business As (DBA), if applicable § 3. Address 1 * 4. Address 2 § (apartment/suite/floor and number) 5.

City * 8. Country * 10. Telephone Number * 6. State * 7.

Postal Code * 9. Province § 11. Extension § 12. Federal Employer Identification Number (FEIN from IRS) * 13.

NAICS

Code * B. Employer-Client Point of Contact Information 1. Contact’s Last (family) Name * 2. First (given) Name * 3. Middle Name(s) § 4.

Contact’s Job Title * 5. Address 1 * 6. Address 2 § (apartment/suite/floor and number) 7. City * 10.

Country * 8. State * 9. Postal Code * 11. Province § 12.

Telephone Number * 13. Extension § 14. Business Email Address * For the public burden statement, please see the Form ETA-9142C, General Instructions. Form ETA-9142C, Appendix A FOR DEPARTMENT OF LABOR USE ONLY Page A.1 of A.1 CW-1 Case Number: __________________ Case Status: __________________ Determination Date: _____________ Validity Period: _____________ to ____________