EASTERN KENTUCKY UNIVERSITY
SELF-IDENTIFICATION FORM
(EKU Employees Only)
Eastern Kentucky University is required by law to report and maintain certain types of statistical information. In order to insure the accuracy of this information, all new employees are asked to self-identify. In addition, federal regulations concerning Medicare require the University to maintain information on spouses* of employees for purposes of determining benefits eligibility.
Please make an entry for each item listed below and certify the accuracy of this information with your signature.
1.  Are you retired from the Kentucky Teachers' (KTRS), or Kentucky Retirement Systems (KERS, SPRS, CERS) or any city/county municipality in Kentucky?     Yes No
              If yes, give effective date:    
2. Do you currently have an active account with KTRS or KERS?     Yes No
              If yes, give date initiated:  
3.  Have you ever been affiliated with EKU in the past?      No Student Employee Other__________
              If yes, give dates:  

4.  Date of Birth:  

5.  Sex: Female   Male
                        (MM/DD/YYYY)

6. Home Address:

7. Phone:

Home:

Other:

8.  Race:  (Please Check) 9. US Citizen: Yes    No
 
White
Black
Asian or Pacific Islander
American Indian or Alaskan Native
Hispanic
Other
If no:

Home Country:

Original date arrived in US?
10.  Veteran Status:  (Please Check all that apply)
Non-Veteran, N/A
Vietnam Era Veteran
Special Disabled Veteran
Other Eligible Veteran* please specify  
Other veteran
Active Duty Military Separation Date: (mm-dd-yyyy)
11.    
          Spouse's Full Name              Date of Birth

12. Emergency Contact & Phone #'s:

Name: Phone 1: Phone 2:

13.  (Optional) Are you disabled?   Yes   No. If answer is yes, does your disability require
     any accommodation in order for you to perform the essential functions of your employment
     responsibilities?
     
14.  I certify that the information above is correct and complete to the best of my knowledge.
NAME (Please print name as it appears on your social security card.)
SIGNATURE
SOCIAL SECURITY NUMBER
DATE
* You may request the qualifying campaign/expedition guide from Human Resources.