NetStudy 2.0 Authorization Form : Roots Wellness Center

Completion of this form is required to allow us to submit the NetStudy 2.0 background study required for your position.

First Name*
Middle Name*
Enter "NMN" if you don't have a middle name.
Last Name*
Permanent Physical Address*
Mailing Address if different from physical address
Hair Color*
Eye Color*
Race*
Height*
Weight*
Gender*
Driver License or State ID Number*
State Issued by*
Driver License or State ID Issue Date:*
Expiration Date*
Social Security Number*
Date of Birth*
Country/State/County/City of Birth:*
Have you lived in any STATES, other than Minnesota, within the past 5 years?*
- Yes
- No
City 1
State 1
Date Span 1
City 2
State 2
Date Span 2
City 3
State 3
Date Span 3
Have you been known by any other names or aliases?*
- Yes
- No
Alias 1 First Name
Alias 1 Middle Name
Alias 1 Last Name
Alias 2 First Name
Alias 2 Middle Name
Alias 2 Last Name
Alias 3 First Name
Alias 3 Middle Name
Alias 3 Last Name
Have you ever been previously disqualified from providing direct services following a background study, or had to request reconsideration?*
- Yes
- No
If yes please explain*
Do you authorize Minnesota CarePartner/Roots Recovery to submit a NetStudy2 Background Study on your behalf to determine eligibility for direct care services in Minnesota?*
- Yes
- No
Please upload a photo of the license or state ID you used to complete this form.
Drop files here or

Max. file size: 32 MB.
Signature*
By signing below you attest that all of the information you have provided on this form is accurate and that you authorize a background study submission using this information.
Hidden
Signature Date
MM slash DD slash YYYY