Form Eta-9043c - Business Confidential Data Request

Form Eta-9043c - Business Confidential Data Request - 2009 Page 3

Business Confidential Data Request

U.S. Department of Labor

Firms Who Work on a Contractual

Trade Adjustment Assistance Program

OMB No. 1205-0342

Basis

Expires: 1/31/2010

Compliance Date:

Affirmation of Information

The information you provide on this form will be used for the purposes of determining worker group eligibility. Knowingly falsifying

any information on this form is a Federal offense (18 USC § 1001) and a violation of the Trade Act (19 USC § 2316). By signing

below, you agree to the following statement:

“Under penalty of law, I declare that to the best of my knowledge and belief the information I have provided on this form is

true, correct, and complete.”

NAME AND TITLE OF COMPANY OFFICIAL:

SIGNATURE OF COMPANY OFFICIAL:

DATE:

E-MAIL ADDRESS:

TELEPHONE NUMBER:

FAX NUMBER:

Please provide contact information for individuals who may be contacted with follow-up questions, if different from

the company official signing the affirmation.

Part 1

Part 2

Name

Title

Phone – Work

Phone – Alternate

Fax

E-mail

Page 4 of 4

ETA-9043c

For more information, visit our Web site at

Rev. 4/09

Form Eta-9043c - Business Confidential Data Request - 2009 Page 3