Applicant Key Individual Certification Form
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1Michigan Strategic Fund and Michigan Economic Development Corporation
Applicant Key Individual Certification Form
Applicant Employer Tax
Applicant (business entity to receive incentive) legal name
Identification Number (EIN)
__________________________________________________________________________________
___________________________
Applicant entity address
_______________________________________________________________________________________________________________
AppliCAnt kEy inDiViDUAl
List the applicant’s CEO or the similarly situated position in charge of the applicant’s executive operations; CFO or the
similarly situated position in charge of the applicant’s financial affairs; COO or the similarly situated position in charge of the
applicant’s daily affairs; and the person(s) responsible for managing the incentive for the applicant.
CEO
or the similarly situated position in charge of the applicant’s executive operations
Full first, middle, and last name (full middle name mandatory)
Date of birth
Residence address
Business phone
Email
CFO
or the similarly situated position in charge of the applicant’s financial affairs
Full first, middle, and last name (full middle name mandatory)
Date of birth
Residence address
Business phone
Email
COO or the similarly situated position in charge of the applicant’s daily affairs
Full first, middle, and last name (full middle name mandatory)
Date of birth
Residence address
Business phone
Email
person responsible for managing the incentive for the applicant (if applicable)
Full first, middle, and last name (full middle name mandatory)
Date of birth
Residence address
Business phone
Email
CErtiFiCAtiOn
I have the authority to submit this form on behalf of the applicant and authorize the MSF, MEDC, AG, CCO, MFO, or any of
their designees to perform background checks on the applicant and its key individual.
Signature ____________________________________________________ Title _________________________ Date ______________
revised October 2013
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Parent category: Business