Debt Management Employment List Note: Complete a separate form for each branch office ­ Make copies as needed FIS 0511 (08/16) Department of Insurance and Financial Services Employee List for: Firm Name Firm's Home Address Branch Office Address Branch Manager's Name Branch Phone No. Employee's Name and Title (List Alphabetically) Certified Provider Date Employed as Counselor *Date of Certification Signature of Officer, Director, Partner, Proprietor or Member Date *Submit copy of certification certificate from Michigan approved provider. 1975 PA 148 as amended requires submission of this form by applicants for a license to do business as a debt management company. Failure to complete and submit this form properly could result in denial, suspension or revocation of your license. American LegalNet, Inc. www.FormsWorkFlow.com