Mn Department Of Human Services Background Study Data Form

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Complete Mn Department Of Human Services Background Study Data Form with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.

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MN Department of Human Services Background Study Data Form

1. Complete this form thoroughly

o The information must match exactly to your Photo ID

2. Print out form and submit with appropriate documentation to M State Student Services

o Attach photo copy of Current State ID, Military ID or Passport

First Name:

Middle: Last Name:

Select Your Program

Program: ________________________________ Course: ________________________________________

(Ex. NURS 1415 Nursing Clinical I)

Address:

______

CITY:

State:

Zip:

_____

DOB:

________ Place of Birth: City: _______________________________ State: ___________

M State Email Address: _________________________________ @my.minnesota.edu

(Ex: jane_doe@my.minnesota.edu or commons names jane_smith2@my.minneosta.edu)

Select Gender

*Social Security Number: ____________________ Race:

_____ Gender:

________

(

providing the SSN is not required, but failure to do so will likely result in a repeat proof of photo ID and fingerprinting for a future MDH background study)

Select Hair Color

Select Eye Color

Height: _____ Ft. _____ In. Weight: _______

Hair Color: Eye Color:

(pounds)

List ALL previous Names or Aliases:

First Name:

Last Name:

1. ___________________________

1. __________________________________

2. ___________________________ 2. __________________________________

3. ___________________________ 3. __________________________________