U.S1 Department LaborEmploym�nt and Training Administration

0MB Control No. 1205-0134Expiration Date: December 31, 2018

Agricultural and Food Processing Clearance Order ETA Form 790 drden de Empleo para Obreros/Trabajadores Agricolas y Procesamiento de Alimentos

{Print or type In each field block - To include additional Information, go to block# 28 - Please follow Step-By-Step Instructions) (Favor de usar letra db molde �n la sollcitud - Para inclulr informacl6n adicional vea el punto # 28 - Favor de seguir las instrucciones paso-a-paso)

1 . Employer's and/or gent's Nf:;me and Address (Number, Street, City, State

and Zip Code / No J

bra y Di �cci6n del Empleador/Patr6n y/o Agente (Numero, Calle, Ci ,dad, Est, do y C6digo Postal ):

LIM Growers. Inc. ' ! ' Lewis J. Myruski Ill :65 Bailey Road, New ;Hampton'. NY 10958 (mailing) 27 Maloney Ln., Gos�cn, NY (0924 (physical)

' L Steven McKay, Agent j (3007 County Route 2p, Hudson, NY 12534 info@h2expressinc.com, 518-491-0109, 866-210-1791 fax

; t Federal Employer lde1lificationjNumber (FEIN) / N(Jmero federal de ldenlificaci6n del Empleador: 45 '426 5832' I ,.

b)Telephone Number I Numero ?� Telefono: 845- 651-1981tia c)Fax Number/ Nulnero de Pax: none

I . ! .

d)E-mail Address/ Dlrepci6n de 06rreo Electr6nico: pm ruski hvc.rr.comAddress and Directio�s to Wor� Site I Domicilio y Direcciones al lugar detrabajo: ,

1 : 27 Malonev Lane, Goshen. NY: l 0924 Pulaski Ih�y. to Ma1t1ney Lon ,: Goshen, NY

(Owned by fixed-site rarmer) ! : t'

I. Address and Directio1s to Hous(ng I Domicilio y Direcciones al lugar de vivienda: 35 Malonty Lune. Ooshen, NY 10924

Pulaski Hwy. to Malqney Lan�; Goshen, NY

House owned by emqloyer I:Description of HoJsing / DeJcripci6n de la vivienda: Wood -framed house , 3 bedrooms living room, bath oom, kitchen/dining room, /fully furnished, all utilities provided: 6il heat, el ctric; capacity XX Orange Regional Hospital, Alamo is closest riledical tadi!ity; recreation possible: jog, satellite TV, Internet, bike, fish Capacity: 8 1/17/18 RC

I Nos. 4 through 8 for STATE USE ONLY

Numeros 4 a 8 para USO EST AT AL

4. SOC (O.NET/ OES) OccupationalCode/ C6digo Industrial:

5.Job Order No. I Num. de Ordon deEmpleo:

J./5:LO 9 /OD a. SOC (ONET/OES) Occupational N'{_ I� .3 7 5 5 �

Title / Titulo Ocur.acionalA 9 r, l,U / fu i €() IM.f'm/ ;t

-------='/.!.,-U. -·"""-=-..::..:s

__. _______ �-----1 6. Address of Order Holding Office (include Telephone number)/ Direcci6n dela Oficina donde se radico la oferta (incluya el numero de telefono):

a. Name of Local Office Representative (include direct dial telephonenumber) I Nombre del Representante de la Oficina Local (lncluya elnumero de telefono de su linea directa).

7. Clearance Order Issue Date/ Fecha de Emisi6n de la Orden de Empleo:

I I .2 I c:i-o I 'if8. Job Order Expiration Date I Fecha do Vencimiento o Expiraci6n de la Orden

de Empleo:1 / :l. "f :l-0 / f

9. Anticipated Period of Employment I Perlodo anticipado o previslo de Empleo:

From I Desde: 03/15/2017 To I Hasta: 12/0712017

10 Number of Workers Requested I Numero de Trabajadores Solicitados: 4

11. Anticipated Hours of Work per Week I Horas Anticipadas/Previstas deTrabajo por Semana. Total: 40

Sunday I Domingo___ Thursday /Jueves_-'--7 __ Monday I Lunes __ 7_ Friday I Viernes 7 Tuesday I Martes 7 Saturday I Sabado 5 Wednesday I Miercoles_7 __

12. Anticipated range of hours for different seasonal activilies: / Rangoprevisto de horas par alas diferentes actividades de la temporada:

Plant crops 40 hrs/wk Water, fertilize. prune plants: 40 hrs Harvest vegetables: 40 hours per week Maintenance: 20 hours er week

13. Collect Calls Accepted from:/ Aceptan Llamadas por Cobrar de:

Employer/ Empleador: Yes / Si D No XXO

0 �©rnowrn

JAN O 3 2018

By

5 1/17/18 RC

14. Describe how the employer intends to provide either 3 meals a dayTo'"each worker or furnish free and convenient cooking and kitchen facilities for workers to preparemeals/ Describa como el ernpleador tiene la intenci6n de ofrecer. ya sea 3 cornidas al dia a cada trabajador, o proporcionar gratuitarnente inslalaciones para cocinar.

Transportation provided weekly to purchase food and supplies; beneficiaries will buy and prepare their own food in fully furnished kitchen.

2

Referral Instructions and Hirihg Information / lnstrucciones sobre c6mo Reforir Candidatos/Solicitantes - (Explain how applicants are to be hired or referred, and the Employer's/Agent'$ available hour to interview workers I Explique c6mo los candida!os seran coniratados o refendos, y las horas disponibles del emp!eador/agente para entrevistar a los tn�bajadores). See instructions for more details I Vea las InstruccIones para mas detalles.

Contact employer: Louis Myniski directly ut 845-355-3868, or 65 Bailey !U, New I lmnpton. NY !0958, Generally available 8 pm to 5 pm for calls.

Or apply through:nearest NYS D0L One Stop Career Center. Please contact (877)4Mi-9757 to locate nearest State Workforce Agency offke.

Job description and r!)quirements / Descripci6n y requisitos del trabajo: Drive and control farm equipment of 50 to 160 I IP or more to till soil, plant, cultivate, and harwsl crops (Onions. baby gr,·cn�. soy bean,, hay). Bale and/or buck hay and other crops. Operate stationary ocquipment to perform post-harvest tasks such as husking. shelling, threshing. Must understand basic English fbr saf�ty concerns. Six months verifiahk work experience in above is required.

Maneja y controbr eHuipos du la nnca 0ntre 50-160 caballos o mas para harar, eultivar y cosechar eultivos. l!acer pacas y n:cogerlas de! campo. Operar eqnipos post-cochesa para pnwcsar los cultivos. Hay que entcnder ingles basico para scguridad. Requisito de 6 meses experiencia en lo mencionado mriha.

1. Is previous work experience required?/ Se require previa experiencia? Yes I Si XXO No O If yes, number o f months required: l Si es asi, numero demeses de experiencia:

2. Check all requirements that apply:0 XX Exposure to Extreme Temp. I Expuesto a Temperaturas Extremas0 XX Frequent Stooping I lnclihandose o agachandose con frecuenciaOXX Lifting requirement I Lev,antar o Ca rgar __ JO __ Jbs./libras0 XX Repetitive Movements / Movirnientos repetitivos

3

---------------------�--� ""�-<n>�',>M• ' ------->•••-•-•••••-----� 15. Waqe Rates, Soecial Pav Information and Deductions I Tarifa de Paoo. lnformaci6n Sobre PaiJ0S Especiales y Deducciones (Rebaias)

Crop Activities Hourly. Wa9e Piece Rate i Spec1ai Pay Deductions' Yes/Si No Pay Penod;

Cultlvos Onions, S3lmio por Hora tmby grnens, soy

beans. hay

Plant $12.83

Irrigate $12.83

Remove weeds, $12.83

prune .•

Harvest and pack $12.8,3

Maintenance $12.83

Unit(s) etc.} Pom,do de Pagos Especlales Deduccione;;-

Pago por P1oza ! (Bono, etc.) j !

Unidad(esi n/a n/a Social Security/ xxO 0 Weekly I Sema

___ l3eguro Social n/a n/a Federal Tax! xxo 0 xxO

lrnpuestos Federales

,-., ·•"-°' ""--•---•- ••= v.,�•=•-,,.�-"

n/a n/a State Tax xxO D Bi-weekly/ /lmpuestos Quincenal Estalales

nla nla Meals I Comidas 0 xxO 0

.. -,.-,---.---�--··-

n/a n/a Other ( specify) I xxo Monthly/Mensual Otro (espocifica)

0

,,,,.,,

. ...................

• Other/Otro

0

16. More Details About the Pay/ Mas Detalles Sobre el Pago

Federal tax option: Foreign H2A: worker may choose to have federal taxes deducted Opcion de los impuestos federales: Trabajador extranjero H2A puede eligir si quiere deduccion de impuesto federal.

17. Transportation Arrangements I Arreglos do Transportaci6n

Employer agrees to reimburse inbound transportation and subsistence expenses ($12.07 per day for a maximum of$51.00 as specified by regulations) to each worker and any person, government agency, or private organizationwhich on behalf of the worker has paid or advanced such transportation and subsistence expenses from theresidence, place oflast employment, or place ofrecruitmcnt to the job site after the worker has completed 50% ofthe stipulated period of employment, from initial date of need or from the day after actual arrival of worker if laterthan the stated date to report. Return expenses also paid.

4

�----------------·-·--------·---,:::�-----,-------..,.---�----�--c-c----------.

18. ls it the prevailing practice to use Farrn Labor Contractors (FLC) to recruit, supervise, transport, house, and/or pay workers for this (these) crop activity(ies)? I LES la practica habitual usar Contratistas de Trabajo Agr\cola para reclutar, supervisar, transportar, dar vivienda, yio pagarle a los trabajadorespara este(os) tipo(s) de cosecha(s)? Yes I Si l:l l�o xxO

If you have checked yes, what is tile FLC wage for each activity? I Si contesto "Si," cual es el salario que le paga al Contratista de Trabajo Agricola porcada actividad?

--·--·-�-------------------------------------------------i

19. Are workers covtlred for Unemployment Insurance? I lSe le proporcionan Seguro de Desempleo a los trabajadores? Yes/SiO No xD

20 Are workers covi,red by workers' compensation? I lSe le provee seguro de compensaci6n/indemnizaci6n al trabajador: Yes/Si xD No D

21. Are tools, supplies, and equipment provided at no charge to the workers? i lse les proveen herramientas y equipos sin costo alguno a los trabajadores?

Yes/Si xCJ No Cl

22. List any arrangernents which have been rnade with establishment owners or agents for the payment of a commission or other benefits for sales made toworkers. (If there are no such arrangements, enter 'None".) I Enumere todos los acuerdos o convenios hechos con los propietarios del establecimiento osus agonies par� el pago de una comision u otros beneficios por ventas hechas a los trabajadores. (Si no hay ningun acuerdo o convenio, indique"Ninguno".) None

23. List any strike, work stoppage, slowdown, or interruption of operation by the employees at the place where the workers will be employed. (If there are no such incidents,enter 'None".)/ Enumere toda huelga. paro o interrupci6n de operaciones de trabajo por parte de los empleados en el lugar de empleo. (Si no hay incidentes de estetipo, indique 'Ninguno".) None

'--------�---;-------------------------------------------'

5

I 24. IS this job .ordet lo be piaci.iinconnection With a futu<e AppiK;atioritoirem�iorn')' Employmem Cert1f1cation for H·-2A woik&r://TZif�iaorcte� d(;·f\!f.Oleo.i1a.q/co pues\,1 en coner:ion con una Mura solic1t1Kl de c1:rlificac!6n de omp1(jo t0m?J1 ;;; para hib;.jadoros H ·21' '!

vcs!Si xQ No a

25. Employer's CertillcatiJn': Th,s job orde;·;;escribes'iha-;;·a�;;rf.;;;;·;;;Jcondl'Uoriiiot the emp1ovri1erii"�ii1Qottiiredby mo Md containi; al\ tt1e materialterms anrJtQMHio1,s ol the job. l CerlIlicacion dill Empl(lador: Esta O'den de lrabajo describe los illrminos y cordicion,H; dQl smpleo que sn le otmoo. ycon!ieoe !ocfos los. ter/ri,nos y cor.,lii,:iones (nak•riales ofr&cidou

Le'A·is J.. Myn.is�i lH, Owner &rnployor' iofed Na/He & Tiilfl f Nombre, rnvio er Leva cW Molde/i:r,prorta ,Jet E:·11::,limcw

12/2T20! 7 Dalij I Fi,,;na

READ CAREF4LLY. In view of the slat:J!otily eslabiinhed basic ftit,d1on of tho Emp1oymenl Ser-,K;€ a� /l r,c,foa labN eXGhange, !Mt 1;;, as a !orurn for bringing fogether employtirs and job $BOko1s. neithor !fl& Emp!oyrr,e11t and T r<11ning AdrniniWal1on (EI A) om the $tate agencies are gu11rn1:tots of the accuracy or iruthfuJnese of i,nforrn:itioo c�ntafned an job ord(!t-s suorriitied by em1>ioy€/rn. Nor ooes any ioh order aci:;epted er recruited upon by ihF Amern:an ,Joli Center constitute a coQtrachHll jo� 0f!er to wt11ct1 the Mwlcari Job Center. £TA ur J Slate a�ency is in any way n party.

t.eA CON CUIDAPO. En vi&la do ra funci6n bar�ca eel Smvicio d,, Empleo (>statitecida p,:11 ley. coma una enti<Jacl dn rr1le1car-1b«:1 fat1ornl �i0: v.:,rntsiones, es dedr, como un foro para reunir II loo cmpleadores y los sol:citante;; \le emplt10. ni E.'f A 11i !as agimcirn, del esllldn puEir.lon garnn!i:uir la exacmuct o vcrad<lad do (a informacion tontenicta en Ii.ls ord,HWtS de ltabajo somet1das por Jos. empleadores. :,11 ningun.J or den de tr abaJo aceptado o c'.cntratado en el Centro oe Cairer�s iArnerican Job Center) consh!uyen vrm olerta de lnabaJl'.i contractua•es a !as quo el American J,;b Center, ti Ao u,1 orgarnsrno est,1t:,i\ fJS de rnngtm� mane:il una ctn ias partM.

PUBLIC BUROEN STATEMENT Tim public 1&l)orting burden tor r(ls1xmding to ET A Fam 790, whi:::n 1s rnquireil !0 oow,n or mtain benefits {4,t USC 3S01 ). is es!innted !c be <'lP?f OXima!tly- 60 minutes par re$ponAf,, inc!ui:ling tlmc, fm n,vitM1ng it1$lrudions, siilmch1ng ex1s!irtq data sources. gathering aM rnv!ewin;J \lie et•llet.Uon The oublic need not respond to !his colle;;tion of �lfonna!ion v11\f/S$ it tli\1piays a currefltly vaiid OMe Co11uo1 NJmbor. THs is pvb1ic inforrnation ard Hwe is no e�p.ict:it\On o! ccntki.;mharity. SHnd comments regarding ihls burdan es\imaw or any ot�er aspec! of this collsction, mcluding suggestions !or reducing this burden. t0 u1e U.S. Oepartr,,ent of labor, Employrr.Mt and Trai'linU Mnlinislrniion, Office of Workfor,:e lnve$tment Room C-451 D. 200 C,,rs•ituti<i,, Av1,11:<1i. NW, Washington, fJC 20210.

OECLARACION OE CARGA P08UCA La ()atga de infi:Jm1.ir.:ion public« parn re&ponder a ;a FNfl'.a ET A 71:JQ, QL<'- so requiem par" oblener o retener bel\Bficios (44 USC 3501 /. se es!lma en aprox!madame11le 60 mlnutos por re$puesta. mciuyendc el !iempo p,1ra rev,�ar ias i11st1uwm1es, ouscar h.Hntes do datos existen:es. mcopi!a, y 1ev;s;,r !a cok!ccion. El publico no tiene p.1r que rt!Sponcter � es!a recop11ackin df! mform�i()n a rienos qoo rnueste w1 numero dv control 0MB va!:do. Esfa informaci6n e:s p(1blicn f no hay ningw,a exr/4cta!iva de c,mft.lencia!idad. Envle sus comenlartoo \,C-Om& de esfa carg,) c; ::•;a!qrnGr ctn> asptlcio dtl esla co1owon, induyern:lo suge:enclas p;,ra teducir ew, carga, at IJ,S. Oepariment ol Labor, Employrrient arid Trail)ing Adrninistrn!1<;:1, 0fiico ol vVorkfo,�e !Me:Wnont, Room C-4510, 200 Co11sti!ution Ave11u$, NW, Was!1iogto11, DC 20210

6

i

26. Use this section to provide additional supporting information (including section Box number). Include attachments. if necessary. I Utilice esta secci6n para proporcionarinformaci6n adicional de apoyo: incluya el numero de la secci6n e incluya arcllivos adJLmtos, si es necesarioNone

7

20 CFR. 653.501 Assurances

INTRASTATE AND INTERSTATE CleARANCf ORDER

The employer agrees to provide to workers referred through U1e clearance system the number of hours of work per week cited in Itt1m 11 of the clearance order for the week beginning with the anticipated date of need, unless the employer has amended the date of need at least 10 working days prior to the original date of need by �o notifying the Order-Holding Office (OHO). If the employer fails to notify the OHO at least 10 working <.1ays prtor to ttie original date of nc1ed, the employer shall· pay eligible workers referred through the intrastate/interstate dearance system the specified hourly rate or pay, or in the absence of a specified hourly rate or pay, the higher of the Federal or State minimum wage rate for the first week starting with the origmal anticipated date of need, The employer may require workers to perform alternative work if me guarantee is invoked and if such alternative work is stated on the job order.

The employer �grees that no extt.msion of employment beyond the period of employment shown on the Job on:t(;r will relieve the empfoyer from paying the wages already earnec:J, or specified in the job order• as a term of employment, providing transportation or paying transportation expense? to th� worker's home.

The employer 'assures that all working conditions comply with applicable Federal and State minimum wage, child labor, sodaf security, health and safety, farm labor contractor registration and other emp!oyment�related laws.

The employer agrees to expeditiously notify the OHO or State agency by tetephon1:: immedrately upon learning· that a crop is maturing earlier or later, or that weather conditions, over recruitment, or other factor-s have changed the terrns and conditions of ernptoyrnent

The employer, if acting as a farm labor contractor, has a valid farm labor contractor registration certificate.

The employer assures the ,wallability of no cost or public housing whkh meets applicable Federal and State stanpards and which Is sufficient to house the speofied number of workers requested throughthe clearance system,

The employer <i!lso assures that outreach workers shall have reasonable access to the workers in the conduct of pu.treach activities pursuant to 20 cm 653.107,

Employer's Name; Lewis J. My ruski II 1, Ov,,ncr Date: 12/22/2017

Employer's Slgnature4�:�-

Besides the material tjllrms and conditions of the employment, the employer must agree to these assurances if the job order is to be placed as part of the Agricultural Recruitment System. This assurance statement must be signed by the employer, and it must accompany the ETA Form ?90,

g

Form ETA 790 Attachment State of: NY Terms and Conditions/Clarifications and Assurances/ Additional Information

A: CLARIFICATION OF ITEMS ON FORM ETA 790 Item 3: Housing a. Housing and utilities are provided at no cost to H�2A workers and those workers incorresponding employment who are unable to return to their place of residence thesame day.b. Housing beds, bedding, and mattresses will be furnished at no cost to the workers.c.1 Hous_ing will be clean and meet the applicable Federal and State housing standards.d. Workers wrn be responsible for maintaining housing and surrounding areas in a neat,clean manner.

Item 14: Board Arrangements Employer will not provide three meals per day. Etnployer will furnish free dishes, cooking utensils and convenient kitchen and cooking facilities. Employer will provide transportation to assure workers access to stores where they can p�uchas� groceries and/or other incidentals, and/or medical necessities.

Item 16: Job Specifications a; Workers must be able to demonstrate that they are physically able to perform the work as �escribed. b. The employer will provide NIA days of training and/or allow NIA days of work forworker to reach production standards if applicable.c. ProduHtion Standards (if applicable): After completion of training or break-in period,employer will expect worker to: NIA

di Employer may terminate worker with timely notification to the NPC and OHS, if theworker:1) Refuses, without cause, to perform work for which the worker was recruited and hired;2) Comlnits serious acts of misconduct;3) Fails, latter completing any training or break-in period, to reach production standards(if applicable); or4) Aban,fons Job ("Job Abandonment") - is absent for five consecutive previouslyscheduled days without prior notification to employer.

Item 17. Wage Rates, Special Pay Information and Deductions

The employer will offer, advertise in its recruitment, and pay a wage that is the highest of the AEWR, the prevailing hourly wage or piece rate, the agreed upon collective bargaining wage, or the Federal or State minimum wage, except where a special procedure is approved for an occupation or specific class of agricultural employment. Employer assures that if a change in the AEWR requires an increase such increase will be paid as of the effective date of the increase. Also if the AEWR is decreased this will b�come;the wage effective on the date of the decrease. a. If pie¢e rate earnings for total hours of work at a piece rate during a pay period do notresult in average hourly earnings equal to the guaranteed minimum hourly rate, theW:orker will receive make-up pay to the guaranteed minimum wage rate.

b. In New York State, the only deductions that can be taken from worker pay are:1. Those required by law, such as Social Security, income tax, and garnishment of

wages; and 2. Those that benefit workers and are authorized in writing, such as life insurance,

or a savings account. Any other deductions are illegal.c. The employer guarantees to offer employment for a minimum of . ("three-fourthsguarantee") of the hours in the workdays during the period of the contract, and allextensions thereof. This guarantee begins with the first workday after the worker's arrivalat the place of employment and ends on the date specified on the job order orextensiohs thereof. In fire, weather, or Act of God terminations (as determined by theCertifying Officer) the . guarantee period ends on the date of termination. The employermust maHe efforts to transfer the worker to other comparable employment acceptable tothe workijr, consistent with existing immigration law, as applicable. If such a transfer isnot affec\ed, the employer must (1) return the worker, at the employer's expense, to theplace from which the worker (disregarding intervening employment) came to work for theemployer, or transport the worker to the worker's next certified H-2A employer,whichever the worker prefers; (2) reimburse the worker the full amount of any deductionsmade from the worker's pay by the employer for transportation and subsistenceexpenses to the place of employment; and (3) pay the worker for any costs incurred bythe work�r for transportation and daily subsistence to that employer's place ofemployment. Daily subsistence must be computed as set forth in paragraph (h) of6$5.122; The amount of the transportation payment must not be less (and is not requiredto be mqre) than the most economical and reasonable common carrier transportationcbarges :tor the distances involved provide the guarantees in Item 19 (a) below.d. Workers will not be required to work more than the number of hours specified in thejob order for a workday or on their Sabbath or federal holidays to meet this guarantee.The worker's average hourly earnings will be used under this guarantee where wagesare paid;on a piece rate basis. Workers who are terminated for cause or who voluntarilyabandori their job are not entitled to this guarantee if employer provides timelynotificatipn to the NPC and OHS.e. On oribefore each payday the employer will provide to each worker in one or morewritten statements the following information: (1) the worker's total earnings for the payperiod; (�) the worker's hourly rate and/or piece rate of pay; (3) the hours of employmentoffered tb the worker (showing offers in accordance with the . guarantee as determinedin paragraph (i) of the regulations at 20 CFR sec. 655.122(k), separate from any hoursoffered over and above the guarantee); (4) the hours actually worked by the worker; (5)an itemization of all deductions made from the worker's wages; (6) if piece rates areused, the units produced daily; (7) beginning and ending dates of the pay period; and (8)the employer's name, address, and FEIN.f. Workers with school age children who have migrated with such children and whodepart in time to return home for the beginning of the school year shall be paid, inaddition ,to the basic wages, any bonus or other incentive payments or other expenses towhich they would be entitled had they stayed the entire job order period.g. The employer will provide workers referred through the interstate clearance system 40h9urs of work for the week beginning with the anticipated date of need, unless employerh1;1s amended the date of need by notifying the SWA no later than 1 O business daysbefore the date of need. If the employer fails to notify the NYS DOL, then the employershall pay an eligible worker referred through the clearance system $ �O (number of $f

9 (-3 .;IJ:)hours of work x AEWR/prevailing wage/minimum wage) for the first week starting with the originally anticipated date of need. If worker referred fails to notify the NYS DOL of

continueo interest in the job at least 5 days before date of need, worker will be disqualiffed from this assurance. Employer will not require worker to perform alternative work if the guarantee cited in this section is invoked. h. Employer will maintain adequate payroll records. Workers will be paid weekly onTuesdaylfor work through the previous Wednesday.

Item 19: Transportation Employer agrees to reimburse inbound transportation and subsistence expenses ($12.07 per day minimum to a maximum of $51.00 per day) to each worker, or any person, !l}overnment agency, or private organization which, on behalf of the worker, has paid or a:ctvanced such transportation and subsistence expenses, from the place from which th� worker has come to work for the employer, whether in the U.S. or abroad to the plac�:of employment, after the worker has completed 50% of the stipulated period of employ111ent, from initial date of need or from the day after actual arrival of worker if later than the :stated date to report. In determining the appropriate amount of reimbursement for meal$ for less than a full day, the employer may provide for meal expense reimburs'ement. with receipts, up to 75 percent of the maximum reimbursement for meals, or $38.25. a. Emplqyer will provide or pay the cost of return transportation and subsistence to eachworker VI/ho completes the employment period, or who is terminated for medical reasons,or: as the: result of fire, weather, or an Act of God (as determined by the CertifyingOfficer), from place of employment to place of recruitment, except if the worker prefersnot to return to his place of recruitment and has subsequent employment with anemployer- see Item 17 (c) above. Employer will not be responsible for providing returncc>st of transportation and subsistence from place of employment to place of recruitmentif the worker voluntarily abandons the job or is terminated for cause and employerpr:ovidesitimely notification to the NPC and DHS.b, The amount of the transportation payment will be equal to the most economical andreasonable similar common carrier transportation charges for the distance involved. Alltransportation provided by the employer will be by common carrier or othertr.,ansportation facilities which conform to the applicable regulations of the InterstateCommerce Commission or the United States Department of Labor. The amount of dailys4bsisteoce will be in accordance with current rates published in the Federal Register(for workers with and without receipts),c.ff requ1ested by the worker, employer will assist in making transportationarrangements.d, Employer will provide transportation, at no cost to the worker, from the employerprovided housing to the actual work site and return at the end of the day.

Item 22:,Workers' Compensation The employer assures that Policy# W1274369-6 issued by NYSIF provides the required insurance for injuries or disease arising out of and in the course of employment. Employer's proof of insurance coverage will be provided to the Chicago Processing Center before certification is granted.

Item 23: Tools and Equipment The employer will furnish without cost all tools, supplies, or equipment required in the perform9nce of work.

B: OTHER CLARIFICATIONS AND ASSURANCES 1. The employer agrees to abide by the regulations at 20 CFR 653.501 and 20 CFR

6155.135.

2. The employer wm expeditiously notify the State agency by telephone immediatelyupon learning that a crop is maturing earlier or later, or that weather conditions, over­recruitment, or other factors have changed the terms and conditions of employment3. Outreach workers shall have reasonable access to the worker ln the conduct ofoutreach activities pursuant to 20 CFR 653.501 (xvi},4, If applicable, the employer is certified in the use and application of pesticides perFederal Environmental Protection Agency and State Department of EnvironmentalConservation requirements. The employer assures that workers hired under this orderwho wm be handling pesticides will be provided appropriatetraining, lf applicable.5. The employer wiH provide to an H·2A worker no later than the time at which theworker a�plies tor the visa, or to a worker in corresponding employment no later than onthe day work commences, a copy of the work contract between the employer and thewprkers ln a language understood by the worker.6, The employer $$Sures that if acting as a farm labor contractor {FLC) or farm taborcontracti:ir employee (FLCE) on the order, he/she has a valid federal FLC certificate orFt..CE identification card,

Employitr Signature-�._1.:.&..-!���-!IJ:'...J.������::i!::� :':l!;zie!:Jz=;;�,=;��=.=---

Oate :; ,;i - M!6- l:J /

To:: NYS Dept of Labor , Foreign lab1.}r Ccrtifo:ation UniHl2A

Stale Office ca1npus • Building 12, Room 200. A.lbany, NY 12240

.USDOL0 ETA

· OFLC Chicago Proc.Centerl l Wes( Quincy Court

; ('.hicago, 1L 60604--2 l 05

Date: Dcce.mber 22, 1017

Frot}1: Lewis Myruski ill 65 Ifaifoy Road >Jew Hampton, :-s;·y l09:5R

Dear Mada1n/Sir.

This Jotter is to inform you that om agent ,viU b<;�: H2Iil<press, lnc. .rno7 Cmmty Route 20, Hudson. NY. l 2SJ4. Phorie 5 l 8-697-5002. Fax 866-21 0- 1 79 l. Cell 5 18,-t:;t .. o JO{}. E m't:lil info(d;h2exprnssinc.cnm Pledsi.! send i1ll correspon.d<:mce to them.

/7�·:m= __

'l 'h;r1k)Jm,

�� Lewis Myrnski m /

.......... .

Owner

Steven Afan l\AeK itv AgC-:nt

OM/3 ApprovM: 1205-0466 Expi�Jiltion Date:�i/3112019

H-2A Application for Temporary Employment Certification

Form ETA-9i42A-APPENDIX A

U.S. Department of Labor

For Use in Filing Applications Under the H-2A Agricultural Program ONLY

A. Attorney o� Agent DeclarationI iJereby c · /fy that I am an employee of, or hired by, the employer listed in Section C of the Form ETA·9142A, and that I havobeen d ted by that employer to act on Its behalf In connection with this application. If t am an agent and not ane,r,ployee Qt the employer, then I have attached a Letter of Representation from the employer. I also certify that to the best of my knowle/ige the Information contained herein fs true and correct. I understand that to knowingly furnish false information in thept,eparation qt this form and any supplement hereto or to aid, abet, or counsel another to do so is a felony p(lnis/Jable by a $250,000fif'/e or 5 yeqts in a Federal penitentiary or both (18 U.S.G. 1001 ).

' .

1. Attorm}y or Agent's last (family) name 2. First (given) name 3. Middle initial

rylcKa� Steven A 4, Firm/Business name

�2 Exijress $. E-Mail 1:1ddress

h2expnjl�s@yahoo.com �- Signaivre 7. Date signed

12/22/2017 '

.

B. Employer peclarationBy virtue of /ny signature below, I HEREBY CERTIFY the following conditions of employment:

· 1 . The Dob oppartunity is a full-time temparary position, the qualifications for which do not substantially deviate from the normaland p_ccepted qualifications required by non·H·2A employers in the same or comparable occupations and crops.

;3,

;4.

7.

The i §pacific job opportunity for which the employer is requesting H·2A ceriificatlon is not vacant because the former occi.jpant(s) is (are) on strike or locked out in the course ot a labor dispute irwoMng a work stoppage. The uob opportunity is open to any qualified U.S. worker regardless of race, color, national origin, age, sex, religion, handicap, or cltiz�nshlp, and the employer has conducted and will continue to conduct the required recruitment, in accordance with regulations, and �as been unsuccesstul in locating sufficient numbers of qualified U.S. applicants for the job opportunity for which certification is s . Any U.S. workers who applied or apply tor the job were or will be rejected only for lawful, Job-related reasons, and the e er must retain records of all rejections as required by 20 CF R 655.167. The �ob oppartunity offers U.S. workers no less than the same benefits, wages, and working conditions that the employer is offerlng, Intends to otter, or will provide to H-2A workers and complies with the requirements at 20 CFR 655, Subpart B. The �mployer understands that it must offer, recruit at, and pay a wage that is at least the highest of the adverse effect wage rate ,ln effect at the time the job order is placed, the prevailing hourly or piece rate. the agreed·upon collective bargaining rate (CB or the Federal or State minimum wage, and, furthermore, that if a new Adverse Effect Wage Rate is published, or the

notified of a new prevailing wage rate during the contract period, and that new rate is higher than the wage det . by the NPC (except the CBA) during the application process the employer will Increase the pay of all employees in the !lame job occupation to the higher rate. For employers subject to the requirements at 20 CFF1 655.200-235, the employer und�rstands that it must offer, recruit at, and pay a wage that Is at least the highest of the adverse effect wage rate, the agrepct-upan CBA, or the applicable minimum wage rate set by Federal or State law or judicial action, for eacl1 month, or porti{:ln thereof. dLiring the job order period. Ther13' are no U.S. workers available in the area(s) capable of performing the temporary services or labor in tho job oppqrtunity, and the employer wlll conduct positive recruitment as specified by the NPC and continue to cooperate with tho SW/\ by accepting referrals of all eligible U.S. workers who apply (or on whose behalf an application Is made) for tile job oppdf1unity untll completion of 50% of the contract period calculated from the first date of need indicated in Section 8.5 of Forni .ET A·9142A. All t�es associated with processing the temporary labor certillcation will be paid In a timely manner.

ETA form 9142y\·- Appendix A TO llE COMl'LETEI) llY EMPLOYJ<�R FROM A CERTJFlE:IWORM ETA-9142A Pug0 Al of A..1

Case Number:.-+------ Crt5e Status:··-·------ Period of Employment: _____ to ____ _

0MB Approv:;t; 1 P05·0460

f!xpif:;tion Dme:'li/31/2019

H-2A Application for Temporary Employment Certification

Form ETA 9142A-APPENDIX A U.S. Department of Labor

8, Durihg the period of employment that is the subject of the labor certification application. the employer: i (i) Will comply with applicable Federal, State and local employment-related laws and regulations, · employment-related health and safety laws;

Will provide for or secure housing for workers who are not reasonably able to return to their permanent residence at t11e end of the work day that compiles with the applicable local, State, or Federal standards and guidelines for housing without charge to the worker; Where required, has timely requested a preoccupancy inspection of the housing and received certification; WIii provide insurance, without charge to the worker, under a State workers' compensation law or otherwise, that meets the requirements of 20 CFR 655, 122(e).

: {v) Will provide transportation in compliance with all applicable Federal, State or local laws and regulations between the worker's Hvlng quarters (Le., housing provided by the employer under 20 CFR 655, 122{d) and, If applicable, 655,230) and the employer's worksite without cost to the worker.

: (vi) Will provide all tools, supplies, and equipment required to perform the duties, without charge to the worker. ; (vii) Will provide meals and potable water, without charge to the worker.

:9. ThelEJmployer has not laid off and will not lay off any similarly employed U.8, worker in the occupation that is the subject of the H·2A'ApoljcaliQn for Temporary Emplqyment Qertifigation In the area of intended employment except for lawful, job related reasi:Jns within 60 days of the date of need, or if the employer has laid off such workers. it has offered the job opportunity that is the $�bject of the application to those laid-off U.S. worker(s) and the U,S, worker(s) refused the job opportunity, was rejected for t�e job opportunity for lawful, job-related reasons, or was hired .

. 10. The;employer and Its agents have not sought or received payment of any kind from the H·2A worker for any activity related to obtalritng labor certification, including payment ot the employer's attorneys' fees, application tees, or recruitment costs. For puri:&ses of this paragraph, payment includes, but is not limited to, monetary payments, wage concessions (including ded�9t1ons from wages, salary, or benefits), kickbacks, bribes, tributes, in kind payments, and free labor.

; 11. The 1 employer has and will contractually forbid any torelgn labor contractor or recruiter whom the employer engages in inter),ational recruitment of H·2A workers to seek or receive payments from prospective employees, except as provided for in DH$ regulations.

'

12, The;employer has not and will not intimidate, threaten, restrain. coerce, blacklist, or in any manner discriminate against, and has pot and will not cause any person to intimidate, threaten, restrain, coerce, blacklist, or in any manner discriminate against, any pE3rson who has with just cause:

:(i) Filed a complaint under or related to Sec, 218 of the !NA (8 U.S.C. 1188), or any Department regulalion promulgated' ' under Sec. 218 of the !NA; ; (ii) Instituted or caused to be instituted any proceeding under or related to Sec. 218 of 1110 INA, or any Department

regulation promulgated under Sec. 218 of the !NA; : {iii) Testified or is about to testify in any proceeding under or related to Sec, 218 of the !NA or any Department regulation ',

promulgated under Sec. 218 of the INA; i(iv) Consulted with an employee of a legal assistance program or an attorney on matters related to Sec, 218 of the INA

or any Department regulation promulgated under Sec. 218 of the !NA; or ; (v) Exercised or asserted on behalf of himself/herself or others any right or protection afforded by Sec. 218 of the INA, or

any Department regulation promulgated under Sec. 218 of the INA 13, The ;employer has not and will not discharge any person because of that person's laking any action listed in paragraph 12(i) through

(V) listed above.; 14, The !employer will inform H·2A workers of the requirement that they leave the U.S. at the end of the period certified by the

Dep�rtment or separation from the employer, whichever is earlier, as required under 20 CFR 655.1350), unless the H·2A wof¼er is being sponsored by another subsequent employer.

:15. The �mployer has posted the Notice of Workers' Rights as required by 20 CFR 655, 135(1) in a conspicuous place frequented by a[I employees,

16. It thtq application is being filed as an H-2A Labor Contractor the following additional attestations and obligations apply under 20CFR;El55.132:

;(i) The H-2A Labor Contractor has provided a copy of the MSPA Farm Labor Contractor (FLC) certificate of registration · if required under MSPA, 1801 U.S.C. et seq., to have such a certificate Identifying the specific farm labor contracting activities it is authorized to perform;

1(ii) The H-2A Labor Contractor has provided with this application a list of the names and locations of each fixed·site agricultural business to which the H-2A Labor Contractor expects to provide H-2A workers. the expected beginning and ending dates when the H-2A Labor Contractor will be providing the workers to each fixed site, and a description of the crops and activities the workers are expected to perform at such fixed site;

·(iii) The H·2A Labor Contractor Is able to provide proof of its ability to discharge financial obligations under the H·2Aprogram and has secured a surety bond as required by 29 CFR 501.9, tho original of which is attached and shows

ETA.Form 9l4ZA.-Appcndlx A TO Im COMPLETEO UY EMPLOYER FROM A CER'flFmOFORM ETA·9142A Page A.2 N' A.'.l

Case ,Numher:. Case Smtus: _____ _ Period ofF111ploymcn1: ...................... ____ t,l -·· ______ _

0MB App/cw,!: 1205,Me<i f:ix()lrat,;;n;Cti1fo. 5/Jt,10 i9

H·2A Application for Temporary Employment Certlffcatlon

form ETA 9142A-APPENDIX A U.S. Department of Lat)or

the narM, address, phone number, and contact p&son ror lhe surnly. and provides the amount ot th.r borxJ (as calculated rn;rsuam to � CHI 501 9/:

(iv) T� H<JA Labor Contr.rictor has engaged 1n and will er19age in recniltnwnt ef1Qft$ In each ar.:,n Df intended employn11;nl in which it has 1ieted n Jixtl<J,&!ie ag1iculrurnI business a� requ•red Jo t'.0 CF R il:i!i. 121, 655.150· 1 tit\ and 655215; 1100

M The H·2A Labor Contrac1or has obt.ifoad from each 11,ect-slte agritultural l>USiness that will pri.wide hcusir.:;i er tmnsportatlon to !he worlwrs a written statemoot slating tnat·

a. All housing "sud oy workers anct owneo. opera,oo, or sacvrc-a by the Hx.Jti-s.ite agr,cuftural busi<,ess complies wilh Hl!J <1f.'p111Jl,ll)/e housing $lal'Kiards in 20 GFH 65'i t 22W) and, lf appi•oable, 655,235: aflti

b, Ail trdnsportation tietwoon the worksite and the work"'rs' living quNters tilat is provldoo by tM fix0d·iite agricultural business compl1r.,s wlth alt applk�a�)!j) f'IWttrill, State, -Of local low'1 and regula!tons and wili provide, at a mi11lrnum, tM same veh\Cle safely stanrn.1rds, ctrlv!l1 !leiinsum, and vehide insuran<'.& as re-.:;ulroo under 29 U,S.C. 1&i1 and 29 CFR part 501\ sxt.ept wt1ere wonwrs' compen$alion I$ ucoo to cover such tnwsp(irtation M described in § 655 J 22(e): and

c. Altw,h 10 tho :itawinent <,ffltitiGates ,.,r \)\.'Cupn11cy lrom tha SWA tor all erripfovef ownoo hui,siog «nd wpies of all drivers· licenses, vehrcie reg,stralior', anct insuranct> policies 101 nil drivers and vehicles trsed to transp<:»t H,:?A wor�IJ(?.,

I he,eby aJ;lmowled9e that 1ha agen! o, iiilMwy tdenUl!oo in section l" 1,1 (lllY) O! the f'om1 E1A,IH4:1A arxl section A nlJtwe ITT authorifefld to 111prU$e<n me for ttie purposo 01 tatior conmu1tion anti. t>y virtue ot my tlgnaum, In Bloc!-. 5 OOf()W, I takil full res;,o�mty f()r 1110 w�curncy 01 any rupresenia\ions 1r11¥1e by my aQAnt or auorney.

I deel�t!l ul'ldtt1· penalty ot perjury that I have rearJ anct rev!e�I Olin appliootlcn ano that to um best ol ,ny kr'°wIooge H'le inlmrmitlrm contalr� therein is trua a11d a,:ca,i1te, I (Jlld11rst,wa that to /inow11iyty tumiSh fr;J/stJ intormtl/ipo 111 tho prepar{J(k)n of tl1iS form ana any supp/8fnent thereto or to ,1id, a/Jilt, or cotm/lf11 rmo/1,er to do so 1$ .t felony punf5hiitl>tti by a $t?M,OOO tme or 5 yem$ in :he Fedrm1J {>(:l{)ltelft{ary N 0011, (18 iLS.c. t{ll)t J.

�killyJ narne�--�,., .. First (glvenJ rm.me

Lewis

Hie

wner

�-�771.: ··--� P1.1bttc Bu�dflfl Statement f Pf!tsons a.re'not ,equ{1ed to n1spotki to !hill 1,'tlll<1cti0n ot i11formation unlos<l ,t d•spl,ws a currently valid 0MB contioi numt:iar. Put>l!C repn1111g bordan tortflil, oollectlori ot lnformwlon is eslimatl)(J to nveiage 1 llour to compietll ttrn form, including the time for ,eviewing in5truc1lons, �archll'lg a�i$iing data i;owrces, gatlwrin�; al)(J mainlolnlng the data neoo,llci, and completing and ievievling tha co«ectkm ot infctrtn11tion,. Thr, 0�19aticn 10:raspond to !his data collection J, requireo to obtailYrlltoin oooofits (Immigration af)(l Nati<maHty Act, 8 IJ.S C. l rn1, et seq.), Please sen;l1¢ornm,mu, reganiirig this ouroon es!lmate or ww ouw1 aspect of this lntormatlon collilctton ro !Im 0/til:e of Foreign labor Ci,rtltics11tion: :(J.S. Oepa11me11t of Labo( • &,x 1?.·200 • �'00 Con�litulionAve., NW. • WMhlng!on, DC • fe!0210 Plet1s& iliL!:\!2.t $Gl1d th@ �plet&d �UOl!Hon to tttis Mdreris,

UM Growrns, Inc. 65 Bailey Road New Hampton, NY 10958

ll . '

Decembet 122, 2017 . ' '

USQOl� ETA

OF�C Chi¢ago Proc.Center 11 West Quincy CourtChid:ago, 1U 60604�2105

RE: WorkJrs' Compensation Policy Assurances

De�r Revi�wing Agent:

Thi� lette�wm certify that I currently have, and will maintain workmen's corr;tpens�tion insurance through the duration of my H2A contract which expiresDecembeti 11 2018.

Sincerely,!

:.• �

lewis Myrluski Ul Owner

. .. . .. . . . . .. . .. . . . . . . . .. 111 111 • .. 11! 11 • • • · · · · - .. . . .. . . .. . . . .. . . . . . . . ill ll t1 lf • • • t1 • • · · .. • • • .. · · · · · · · · · · · · - · · · · · .. . .. . .. . . .. . . _ . _ _ _ _

. . . .. . . . . .. . . . . . . .. . . . . . . . . '! 11 • • • • • • • • • fl' Ill . • • • • • • 11( 11 11 .. 111 • <11 • . .. . fl - . .. . .. . - · � - · - W M 4E II . 11 .. IJ II .. . . . . II - � · · · · · · II .. . . Iii · · · - M ""1;

: : STA TE OF NEW YORK w WORKERS' COMPENSATION BOARD www.wcb.ny.gov : • ESTAOO OE NUEVA YORK - JUNTA OE COMPENSACION OBRERA siatewicte rax une: m-53J-o337 : . .. .

. . NOTI<fE OF COMPLIANCE A VISO DE CUMPLIMIENTO

. .

. . . . . . TO EM�LQYEES

: : IMPORTANT INFORMATION FOR EMPLOYEES WHO ARE • : INJURED OR 'SUFFER AN OCCUPATIONAL DISEASE WHILE: : WORKING.• • 1. By posting this notice anti information concerning your rtghti as an injured : : worker, your employar is incolnpliance with the Workers' C<nnpensation L.!lw. : : 2. 11 you do not no�fy your anlployer within 30 days of the data of your injury your • • claim may be disallowed, so 40 so immediately. . . . . . .

. .

. .

. .

. .

. .. .

. .

. .

. .

. . . .. .

. . . .

. .

. .

. .

• • • •. .. .

. .

. .

. .. .. .. .

. .

. .

. .

. . . .

. .

. . . .

. .

. .

•

. .. .

. .

. .

. .. .. .

. .

. .

. .

. .

. .. . . .

. .

. .

. .

. .. .

. .. . . .

. .

. .

. .

. .

. .

. .

3. You are entit1eb to obtain!any necessary medic.at 1reatment ano &hould do w immediately. · ·

4. YO\l may cilOQse any *tor, podiatrist, Chiropractor or psychologist referred by a nwdic,al doctor that accepts NY Slate Workers· Comptmsation patients and Is eoard aujhorlzed. Hqwever, If your employer i& involvod In a certifioo preferred provideJ organizijlion (PPO) yuu must first be treate<I by a provrdur chosen by your 9mployer �od your employer must give you a written st.itement of your righi!; i:.-0/J�min9 further mooical cam . 5. You shoold ldrl your dcjqlor to file copies cf medical reports coru::ernirig your claim with the WQli<JlJ1>' Compensation Board and with your employer's insurance compapy. which 11 lnd1cated a1 the oo1tom of this form .

' '

o, You may ba eMttlod to lost limo bOMfits if your w(l(k-relatod injury keeps you from work ior more lhan soven oay�, oompols you to worn at kw1N wages or results In penna�i.tnt dlllabllrty to any part of your body. Yoo may be entttled to rehabi.lltalion sll:l\llce& If you ne&d help returning to work,

7. You should nQI pay any medical pro\rldera dircctty. Thuy should send their bills to your emplpyer's insurance carrier. If there is a dispute. the ptovider must wait until tho Board makes 'a decision before it attempts lo collect payment trom you. lf yo(! do not ipurwe yoor claim vt the Board rule11 that your injury is not work-related, you may be responsible for the payment of Iha bills .

8. Yoo are erifitfoo to ; be repms&nt&d by an attomey or liceJISad rapraoontativc, biil It is no! ; roquired. If you do hire n �presonlative do not pay him/her dirtl'.ctty. Any it-0-0 will bo set by the Board and will be doducied from your award,

9. If you havo difficulty in pbtainiog a claim form or need help in filling ii 0111, or if yo11 have any other questions or prob lo ms about a job-related Injury, contact any office of the Workers' �pensatioo Boartl,

. ' WORKl:Rli' COMPSNIIA'l'ION EIOAIU) OFFICES . Albany, 12241 • 100 fltoor1W9¥,Menancts • (006) 7ti!H15f 'Brooklyn, 1 1201 • 1 1 1 Living$1on St • Brooklyn · (600) 877-1373 Binghamton, 139(!1 , Slate Olfice Bklg.-44 rlawley St· (066) 802-3604 Buffalo, 14202 • 3119 Franklin $tteet · (8661 :1 1 1 ,064!,

•Hauppaug,,, 1 1 7118 ·· ite 100 · (600) 681-5354 'Hempstead, 1 1650 · (886) 805-3630 ·New York, 10021:- 215 W, . Manhattar, . (800) 877-13n 'Peekskill, 10566 � 41 North , St · (866) 746-0552 'Oueen•. 1 1 432 • 168-46 91s(Ave. • Jamaica (800) an 1373RochMter, 14614' · 130 Ma,n Stroot West • {!lixl) 21 1 -0644 Syracuse. 13203 • 035 Jamoit SI. · (866) 802-3730

·OOWN$TATE MAIL AOORE$S Claims-mlatad maij for th<! Hawppauga, Hemostead . Peekskiff and all NYC offlca,.!should be mailed to· PO Box 5205 Binghamton. NY 13902--5205 .

INFORMAc,oN IMPORTA!r:M;':!':0e5MPLEAoos aue SEAN �ILESIONADOS O $UFRAN UNA ENFERMEOAO OCUPACIONAL :_

1 MIENTRAS TRABAJAN.1 . Su patwno esta eump!iando la Lay do Componsacl6n Obrera cuando despliega aste oomunicado cot1Cemiante a sus der�hos como trabajaoor lo$lonado.

:1

2. Si ustoo no notifica a su palfono den1ro del teunino de JO dias de haber sufrido su lusion • su rodarnai:ioo podria ser dosesflmada, por eso notifique inrnediatamel\te,

3. Usted \ieoe derecho a recibi< cvalquiar tratami,mto medico necesa110 rel1;1cionado con su ' lasion y d<lbo gostionario inmedintamnnte.

4. Para el trat«mitmto tie cuelquier les,on o enferrnedad relaci<:>n<ldewn ol traoojo, ustoo µuede eBCOger cuatquler medico, podiatra. quiroprac1iW o p:,ioologo (si as relertdo por un : medico autori:rndo) quo este autolizado y acapu, pacieotes de Ill Juntade C<lmponsac16n Obrora. Sin embaft/0, si su patrollO osta .:uitoriz.ado a parucipar uno organil.aolon certlficada • de proveooores prefefldos (Pf'O} usted debera obtener tratamieoto inicial para • cualquier lesion o anfermedad relaclonacla con el trabajo de la correspon<liente • ontidad. Patrono,:, que participen en cualquier de estoo programas estalllecidos por loy o:stan obllgadosa prQveer a sus empleados n<rlificacion escrita expllcando sus derechos y otJligaclones bajo et programa a Que csto acogldo .

ti. Usted dat,era roquorlr de su Medico qua radique copias de los inlonnes medicos de Sll • caso an la Junta de Compensacion Obrara y en Ill compania de seguros de au patrono. qoo so indica al final de E!sta ronoo .

6. Usted Ilene dererro a compe11sacion si su lesion relaclonada oon el traba)o le impkJe • trabajar por ITI8S de !lie!e dias. le obfiga a trabajar a sueldo mas bajo o resulta en incapooidad : pennanenta de cualquier parte de su CU!lrpo. Usted pueoo tenllt detoeho a SllfVicl1>s de • rohabilitacio'n sl neoosita ayuda para regresar al trablljo .

7. No pague a nln9tm provoooor mediOO dlrectarner,to por tralamlenlo de su lesiJn o • enfermedad relaciormda con el 1rabaJo. Ellos debr,n envJar sus facluras at asegumdor de su : patrono. Si el caw es cuestionado, el proveedor debera esperar hast.a que la Junta dl!cida el • caso, antes de inlciar 11esti6n do oobro alguna contra usted. Si usted no trami1a 3u caeo 6 la : Junta falla Que $u feslon o enfermedtld no e$ta relacionada con el trabajo, uated podrta ser • responsable uel pago de las facturas, •

8. No es obligatorio el e.,tar reJ)fesentado en ninguno do los prooedlmlentos de la Junta, poro es un deroctto que usted tiene, el estar representado por abogado o por representante licenclado sl uslod asi lo d(l\l-011. Si es mpresentado. no pague al �bogado o al l'Gpl'Gslinlante licanciado. Cuando la Junta decida su �so, los honomrios seran doterrninedos por la Junta y • descontados de $US beneficlos .

9. SI tiene drficultmJ en conseguir un formulario dt> raciomac�cln o m1ceslta ayuda para llenario d tiene dudas sobre cualquier snuacki11 relacionadu oon una lasl6n o enfermedad comunique$e con la oftcifla 111$S cercana de la Junta •

Kenneth J. MunnellyChair (Presidente)

. .

. .

. . Workers· CorilpeMatlon lkmelits. wllen due. will be paid by {Los beneficios de Compensacioh Obfera, cuandos debioos, ,;orafl pagaclos por}:

: : r---------T-H�E�S-T_A_T_E_IN_S_U_R_A_N_C_E_F_U_N_D _____ _, Name of employer (Nombre de patrono)

: : 199 l::hurcli Street, 111- York, N. Y. 10007 : : (2'12) 31Nl000 . . .

To cancellation: : Effective From ., . . ... Jl?/1�/�()1]' .

: (En Vigor DeSde) (Hasta .,, cancellation) , .

. : .� J�H 3..�9.=l. . .

. . Policy No. . . .: : (Poliza No.) . . . . .._ ______________________________ �. .

. . . .. .<MOS (08-�009) S. l. F. U-30 ·t:,)(lf!lf'!SN •

�R_f;S-('-RllUD CW !;'HAJrl, W()f\i(L�$'C()l#�NSAIIO¾' BOAi:!� ?'f....,Tt or m:w Y('...ttK

LJM GROWERS INC 65 BAILEY ROAD NEW HAMPTON NY 10958

THIS NOTICE MUST BE POSTED CONSPICUOUSLY IN 41110 ABOUT THE EMPLOYElt'S PLACE OR PLACES OF BUSINESS .

Failure by an employer to post this notice in and about tlla employer's place or places of business may result in a $250 penalty for each violation.

. .

. .. .. .

. . . . . . . • • !I! If « • W .. • • # • • I!' • # » If * # 111, • * if ff 11- M # t f It' • • • M • # !Ill; 11 • ft If • If Ill .. * • a W It a • • • # a a # llE If .,; fl • If # • # I! • • • • • • It ti W Ill • • • • a 111 11 .. It # 11 ti " 11 W • W

. .. . . . . .. . . . .. , • • • • • , .. . .. . . . . .. .. . .. . . . .. .. ,i .. .. . .. . . .. . . .. . . . , • • • • • • • • •11t J,Ji • • • .. • • .. w ., .. . . .. • • • 11 w • • • • • • .. l