ETA-9105 Employer Data Form

OMB Approval No.1205-0439

Expiration date: 01/31/07

Employer Data Form

Company/Industry	Location of Facility	Notification Type	Date of Notification		Layoff Date(s)	Number of Affected Workers
		__WARN __Public Announcement by Employer __Other(specify) __None				__ Check if Closure

Date(s) of Rapid Response Actions	# of Workers Contacted	TAA Petition	Number of Planned Participants	Labor Organization Representation
Contact with Employer: _______ Contact with Workers: ________ __None		Date Filed: _____ __Number of Workers Covered __Not applicable

Type of Business	Three-Digit NAIC Code

ETA 9105