PeopleSoft User Affiliate Form

* Email address of person completing this form:

* Affiliate's Legal Name
(as it appears on your Social Security card):

Sex:   Male      Female

* Home address: * City:
* State: * Zip: * County:
Employee ID:

Birth Month and Day
(ex. 0406):

* Employer:

* Department Name and Number
(ex. Purchasing 68701):

* Has the Affiliate ever been employed by the State of Kansas or the Kansas Board of Regents?
  Yes     No 

* Has the Affiliate ever been a student at the University of Kansas or KU Medical Center?
  Yes     No 

Last modified: Nov 05, 2014
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