OMB Approval No. 1205-0439
Expiration date: 01/31/07
The reporting requirements are approved by OMB according to the Paperwork Reduction Act of 1995 under OMB approval No. 1205-0439. NOTE: Persons are
not required to respond to this collection of information unless it displays a currently valid OMB control number. Respondent’s obligation to reply to these
reporting requirements are mandatory (PL: 107-210). Public reporting burden for this collection of information is estimated at 15 minutes.
Send comments regarding the burden estimate or any other aspect of this collection, including suggestions for reducing this burden to the U.S. Department of Labor,
Office of National Response, Room N-5422, Washington D.C. 20210.
(Paperwork Reduction Project 1205-0439).
Employer Data Form
Number of Affected
__ Check if Closure
Date(s) of Rapid
Labor Organization Representation
Date Filed: _____
Type of Business