Free background check form 37
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Michigan Strategic Fund and Michigan Economic Development Corporation
Background Check Disclosure Form
A Background Check Disclosure Form must be completed by the Applicant AND each of the Applicant’s Owners with a
direct or indirect ownership interest of 20% or greater AND each of the Applicant’s Key Individuals listed on the Applicant
Certification Form. However, if Applicant is publicly traded, the applicable entity listed on its Background Check
Disclosure Form must complete this form.
If being completed on behalf of an ENTITY
Entity Name

Employer Tax ID Number (EIN)

Principal Place of Business Address (include city, state, and zip code) Primary Contact Name

Primary Contact Email

If being completed by an INDIVIDUAL
Full first, middle and last name (full middle name mandatory; if none, please indicate)

Date of Birth

Residence Address, if individual (include city, state, and zip code)

Email

Business Phone

BUSINESS INTEGRITY

Please provide a