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NEW MEMBER INFORMATION SHEET (Please Print)NAME: ___ DATE OF BIRTH: ___ ETHNIC BACKGROUND: Black () White ()Asian ()Hispanic ()Indian () Other___FLORIDA ADDRESS:___ NORTHERN ADDRESS:___ EMAIL ADDRESS:
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Go to the website of Minnesota Department of Human Services (MN DHS)
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The Minnesota Department of Human Services
Individuals or entities as specified by the department
By providing the required information accurately and completely
To collect necessary data for program administration and compliance
Specific details as outlined in the form instructions
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