MN Department of Human Services Background Study …

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:

Program: _S_e__le_c_t__Y_o_u__r_P_r_o_g__ra_m_____________ 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)

*Social Security Number: ____________________ Race:

_____ Gender: Sele_c_t__G_e__n_der

(*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)

Height: _____ Ft. _____ In. Weight: _______ (pounds) Hair Color: Select Hair CoElyoerColor: Select Eye Color

List ALL previous Names or Aliases: First Name: 1. ___________________________ 2. ___________________________ 3. ___________________________

Last Name: 1. __________________________________ 2. __________________________________ 3. __________________________________ 4. __________________________________

List ALL previous States of residents within the past five years:

_________________________ (state) from __________ (year) to __________ (year)

_________________________ (state) from __________ (year) to __________ (year)

_________________________ (state) from __________ (year) to __________ (year)

_________________________ (state) from __________ (year) to __________ (year)

_________________________ (state) from __________ (year) to __________ (year)

ID Type: Select Identification for Verification Issued by

Exp. Date

This document will be destroyed once background study information has been entered.

minnesota.edu A member of the Minnesota State Colleges & Universities System.

An Equal Opportunity Educator and Employer

JSH w/HjD 01/01/16

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