CERTIFICATION OF ALIEN EMPLOYMENT* 
   
•  I certify that I am an authorized representative of the applicant and as such am authorized to make the statement of 
   affirmation contained herein.  
•  I certify that the applicant does NOT knowingly employ any person who is an unauthorized alien and that the 
   applicant has complied with federal law (8 U.S.C. § 1324a) requiring the examination of an appropriate document or 
   documents to verify that each individual is not an unauthorized alien.  
•  I certify that applicant is enrolled and will participate in a federal work authorization program as defined in Section 
   285.525(6), RSMo., with respect to employees working in connection with the activities that qualify applicant for this 
   program. I certify that applicant will maintain and, upon request, provide the Department of Economic Development 
   documentation demonstrating applicant’s participation in a federal work authorization program with respect to 
   employees working in connection with the activities that qualify applicant for this program.  
•  I certify that applicant shall include in any contract it enters with a subcontractor in connection with the activities that 
   qualify applicant for this program, an affirmative statement from the subcontractor that such subcontractor is not 
   knowingly in violation of Section 285.530.1, RSMo, and shall not be in violation during the length of the contract.  In 
   addition applicant will receive a sworn affidavit from the subcontractor under the penalty of perjury, attesting that the 
   subcontractor’s employees are lawfully present in the United States. I certify that applicant will maintain and provide 
   the Department of Economic Development access to documentation demonstrating compliance with this requirement.  
•  I understand that if the applicant is found to have employed an unauthorized alien, applicant may subject to penalties 
   pursuant to Sections 135.815, 285.025, and 285.535, RSMo.  
‰  I certify that I have included a copy of the executed E-Verify Program for Employment Verification Memorandum of 
   Understanding between the company/organization and the Department of Homeland Security, United States 
   Citizenship and Immigration Services (DHS-USCIS) and Social Security Administration. 
‰  I am not a business entity as defined in RSMo 285.525 (1) as “any person or group of persons performing or engaging 
   in any activity, enterprise, profession, or occupation for gain, benefit, advantage or livelihood.  The term “business 
   entity” shall include but not be limited to self-employed individuals, partnerships, corporations, contractors, and 
   subcontractors.  The term “business entity” shall include any business entity that possesses a business permit, license, 
   or tax certificate, issued by the state, any business entity that is exempt by law from obtaining such a business permit, 
   any business entity that is operating unlawfully without such a business permit.  The term “business entity” shall not 
   include a self-employed individual with no employees or entities utilizing the services of direct sellers as defined in 
   subdivision (17) of subsection 12 of section 288.034, RSMo.” 
•  I certify under penalties of perjury that the above statements, information contained in the application and attachments 
   are complete, true, and correct to the best of my knowledge. 
 
NAME (SIGNATURE)                                             DATE 

NAME (PRINTED OR TYPED)                                      APPLICANT/PROJECT NAME (PRINTED OR TYPED) 

TITLE (PRINTED OR TYPED) 

NOTARY PUBLIC EMBOSSER OR BLACK INK STATE                                          COUNTY (OR CITY OF ST. LOUIS) 
RUBBER STAMP SEAL 
                                    SUBSCRIBED AND SWORN BEFORE ME, THIS 
                                                                                   USE RUBBER STAMP IN CLEAR AREA BELOW. 
                                     
                                          DAY OF                      YEAR   
                                    NOTARY PUBLIC SIGNATURE  MY COMMISSION EXPIRES 
                                                                                    
                                    NOTARY PUBLIC NAME (TYPED OR PRINTED)           
                                                                                    
  MO 419-2484 (10-99)