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New Dimensions Home Health Care

Photo/Fingerprint Background Study

New Dimensions Home Health Care, Inc. · 312 N Tower Rd, Fergus Falls, MN 56537 · (218) 739-5856

Personal and demographic information required by the Minnesota Department of Human Services for your background study.

Identity

Name:  Middle name:  
E-mail:  Primary phone:  
Primary phone type (mobile / home / work):  Secondary phone:  
Secondary phone type (mobile / home / work):  
Address:  
Mailing address (if different):  

Required by MN DHS

Driver's license number:  Social Security number:  
Sex (Female / Male / X):  Race:  Place of birth:  
Eye color:  Hair color:  
Height:  Weight:  

Residence history

Lived outside Minnesota in the last 5 years? Yes / No (circle one)  
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

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.

Signature:  Date: