Form Eta-9042a - Petition For Trade Adjustment Assistance (Taa) - 2009
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3U.S. Department of Labor
Employment and Training Administration
OMB No. 1205-9042
Expires: 1/31/2013
Petition for Trade Adjustment Assistance (TAA)
Section 1. Petitioner Information
Provide petitioner information below. Three workers from the same job location completing this Petition Form must fill in all
three columns. Other petitioners need only fill in the Petitioner 1 column. A union official completing this petition form should
provide the name of the Union.
Petitioner 1
Petitioner 2
Petitioner 3
a)
Name
b)
Title
c)
Street Address
City
State, Zip
d)
Phone – Main
e)
Phone – Alternate
f)
E-mail
g)
Worker Separation Date
h)
Petitioner Type:
Three Workers
Company Official
Union Official
(Union Name _______________ )
(please check one)
State Workforce Office
One-Stop Operator/Partner
Other Authorized Representative
i)
Describe the worker group on whose behalf this petition is being filed:
Section 2. Workers’ Firm / Public Agency Information
Provide information on the firm or public agency employing the worker group. Complete items (a) – (h) regarding the
employing firm or public agency. If the workers are doing work at a location that is different than the worker’s employer (e.g.,
the petitioning workers are employed by a staffing agency but work at a manufacturing firm), also complete items (i) – (m)
regarding the firm or public agency at which the workers perform their jobs.
NOTE: Workers completing this Petition Form must provide information for the location where they work. All other petitioner
types may apply on behalf of more than one location. State offices and One-Stop Operators/Partners may file for workers at
multiple locations of a firm within their State. If you choose to file on behalf of workers at more than one location, please
attach additional sheets as necessary.
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ETA-9042a
Rev. 4/09
Previous forms not usable
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