Employee Background Check Authorization & Data Collection Form
Minnesota law requires some background studies conducted by the Department of Human Services (DHS) to include a fingerprint-based Federal Bureau of Investigation (FBI) record check.
Name
*
First Name
Middle Name
Last Name
Suffix
Maiden Name, Prior Name or Aliases
*
Email
*
example@example.com
Date of Birth
*
-
Month
-
Day
Year
Date
Social Security Number
*
Race
*
Asian or Pacific Islander
Black or African American
White
Native American
Other
Sex
*
Male
Female
Prefer Not To Answer
Current Street Address
*
City
*
State
*
Zip Code
*
County
*
Telephone Number
*
Eye Color
*
Hair Color
*
Height
*
Weight
*
State or Country of Birth
*
Have you lived in any U.S. state other than Minnesota in the last 5 years?
*
Yes
No
If Answered Yes to Above Question, Please list names of City, State or Countries. Please Also list Date of Year Resided (ex: Nashville, Tennessee 2019-2024)
*
Driver's License Number or MN State Issued ID Number
*
Expiration Date of ID
*
Please Upload Photo ID and Social Security Card
*
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Signature *I am signing this form electronically. My name as typed in the signature field is my legally binding signature. I understand that my electronic signature has the same legal effect and can be enforced in the same way as a handwritten signature
*
Today's Date
*
-
Month
-
Day
Year
Date
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