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Photo/Fingerprint Background Study

Personal and demographic information required by the Minnesota Department of Human Services for your background study. Fields marked * are required. Prefer paper? Print the background study instead.

Identity

Name *

Middle name

E-mail *

Address *

Mailing address (if different)

Primary phone *

Primary phone type

Secondary phone

Secondary phone type

Required by MN DHS

Driver's license number *

Social Security number

Sex *

Race *

Place of birth *

Eye color *

Hair color *

Height *

Weight *

Residence history Check if you have lived outside Minnesota in the last 5 years, and list where below.

State 1

City

Years lived there

State 2

City

Years lived there

State 3

City

Years lived there

Other names used

Other first names used

Other last names used (maiden, married, etc.)

Signature

Type your full legal name as your signature *

I certify this information is true and complete, and I understand it will be used to submit my background study to the Minnesota Department of Human Services.

Your information is sent over an encrypted connection directly to New Dimensions' hiring team and is used only for your MN DHS background study. It is never sold or shared outside New Dimensions.