Application for Entrepreneurial Center Certification
North Dakota Department of Commerce
SFN 59162 (7-2009)
ND Department of
Commerce
Economic Development &
Finance Division Use Only
Approved
Denied
Taxpayer Information
Applicant Name
Federal Tax Identification Number
Primary Contact
Title
Telephone Number
Physical Address
City
State
ZIP Code
Mailing Address
City
State
ZIP Code
Website
Email Address
Business Information
1. What type of business incubator services do you provide?
Mentoring
Shared Services
Relationships with Educational Institutions
Marketing Assistance
Accounting/Financial Management
Training
Regulatory Compliance
Other (please describe):
OFFICE USE ONLY
2. Type of business:
Non-profit
For-profit
State Entity
Institution under control of the state board of higher education
Other __________________________________________________
3.
Is this business registered with the Secretary of State?
Yes No
If no, date you will register ____________________________________
The undersigned certifies that the information provided in this document is true and accurate.
Applicant (Please print)
Title
Authorized Signature
Date
Consistent with North Dakota law, information contained in the shaded areas will be kept confidential within the North Dakota
Department of Commerce and State Tax Department.
In compliance with the Federal Privacy Act of 1974, Public Law 93-579, the disclosure of the taxpayer’s social security number or federal
employer identification number (FEIN) on this form is mandatory and is required under Subsection 2 of North Dakota Century Code § 44-04-28.
Failure to provide this information will result in withdrawal of the application.
SFN 59162 (7-2009)
Page 2
North Dakota Department of Commerce
Application for Entrepreneurial Center Certification
Benefits of certification
Certification as an entrepreneurial center provides access to the
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