Clear Form
Michigan Department
MDOT DIGITAL SIGNATURE
Of Transportation
2122 (12/16)
CERTIFICATE REQUEST FORM
INSTRUCTIONS:
The information on this form is required by the Michigan Department of Transportation (MDOT) to verify the
identity of the applicant requesting a digital signature certificate. The supplied information ensures the
returned digital signature certificate matches the identity of the signer. The assigned signature is eligible for
use on all applicable MDOT documents.
This completed form will remain valid until the signer’s digital signature certificate expires or until such time
as the signer needs to create a new digital signature. Each digital signature is unique. If another digital
signature is used, even though it appears similar, it will not validate as the encrypted data within the signature
will not match the previously validated signature information. This will result in the rejection of any document
on which the non-validated signature has been used.
It is the responsibility of the applicant and/or associated company/agency to notify MDOT of any change in
employment status, signing authority, or e-mail address that may impact the validity of the assigned
signature.
Note: Applicants and associated company/agencies may be directly contacted to further
authenticate the identity of the applicant and/or confirm signing authority.
Completed forms must be returned electronically to:
MDOT-eSign@Michigan.gov
SIGNATURE APPLICANT SECTION
APPLICANT NAME (
)
COMPANY/AGENCY
LEGAL NAME
APPLICANT NAME AS TO APPEAR ON SIGNATURE
TITLE
(IF DIFFERENT
THAN FIELD ABOVE)
PROFESSIONAL LICENSURE
LICENSE NUMBER
(PE, PS, AIA, etc.)
E-MAIL
PHONE
CERTIFICATION AFFIDAVIT:
The undersigned affirms all information provided on this form is true and correct. I also understand by signing
below, the digital signature certificate assigned will be used exclusively for State of Michigan contracting
and/or authorized use only.
PRINT OR TYPE NAME, SAME AS SIGNATURE BELOW
TITLE
APPLICANT SIGNATURE
DATE