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.

NAME (Print name as appears on your social security card.)



Please make an entry for each item and certify the accuracy of this information with your signature.
1. Are you retired from the Kentucky Teachers' (KTRS), Kentucky Retirement System (KERS, SPRS, CERS) or any city/county municipality in Kentucky?   Yes No Unsure (if yes, circle one: KTRS   KERS   SPRS   CERS )
        If retired, give effective date:    
2. Do you currently have an active account with KTRS or KRS?     Yes No
              If yes, give date initiated:     Have you withdrawn your funds? Yes No Unsure
3.  Have you ever been employed with EKU in the past?      No Student Employee Faculty
              If employed, give dates:  
      Have you ever been affiliated with EKU in the past?        No Student Vendor Other
4.  Date of Birth:   (mm/dd/yyyy) 5. Sex: Female  Male   Prefer not to respond
6.   Home Address:

7. Phone:

8. (Optional) Race: Do you consider yourself to be Hispanic/Latino?    Yes No
(Please Check all that apply)
American Indian or Alaskan Native
Black or African American
Native Hawaiian or Other Pacific Islander
Prefer not to respond
9. (Optional) Veteran Status: (Please Check all that apply)

Non-Veteran, N/A
Vietnam Era Veteran
Special Disabled Veteran
Other Eligible Veteran *Specify
Other Veteran
Prefer not to respond
Active Duty Military Seperation Date:  
10. US Citizen:    Yes No   (If "No" please complete)
Home Country:

Original date arrived in US:
11. Emergency Contact:

Phone 1: Phone 2:
12.  (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

13.  I certify that the information above is correct and complete to the best of my knowledge.

*You may request the qualifying campaign/expedition guide from Human Resources.                             (Revised 10/22/2010)