"Veterans Preference Request: Self Identification Form" - Kansas

Veterans Preference Request: Self Identification Form is a legal document that was released by the Kansas Commission on Veterans Affairs - a government authority operating within Kansas.

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Download "Veterans Preference Request: Self Identification Form" - Kansas

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Lyon County Courthouse
Veteran’s Preference Request: Self Identification
430 Commercial Street
Form
Emporia, KS 66801
Pursuant to K.S.A. 73-201(c), Veterans shall be preferred for initial employment and first promotion
in the state government of Kansas, and in the counties and cities of this state, if competent to
perform such services. In the event an eligible veteran is not hired for a position in which he or she
has applied, notification will be sent within 30 days by certified mail or personal service.
To determine eligibility, please answer the following questions:
Yes/No I entered the armed forces before Oct. 15, 1976, and separated from the armed forces
under honorable conditions. I served i) on active duty during any war (official dates for war service
are 4/6/1917 – 7/ 2/1921 and 12/7/1941 – 4/28/1952); ii) during the period 4/28/1952 -
7/1/1955; iii) in any campaign or expedition for which a campaign badge or service medal has
been authorized; or iv) for more than 180 consecutive days since 1/31/1955 but prior to
10/15/1976, excluding an initial period of active duty for training under the “six month” reserve
or national program.
Yes/No I entered the armed forces on or after 10/15/1976 and separated from the armed forces
under honorable conditions and was awarded a service medal or campaign badge.
I separated from the armed forces under honorable conditions and have a disability certified by
the U.S. Dept. of Veterans Affairs as being service connected, have been issued the purple heart
by the U.S. government, or have been released from active service with a service-connected
disability.
Yes/No I am the spouse of a veteran who has a 100% service connected disability as determined
by the U.S. Dept. of Veteran Affairs.
Yes/No I am the spouse of a veteran who died while and as a result of service in the armed forces
and have not remarried.
Yes/No I am the spouse of a prisoner of war, as defined by K.S.A. 75-4364 and amendments
thereto.
If you marked “Yes” on any of the above questions and desire to use Veteran’s Preference, please
sign and date this form and submit to the Human Resource Department, along with a copy of your
DD214 form or the DD214 form of the veteran under which you qualify.
Name:____________________________________________
Signature:_________________________________________ Date:_________
Lyon County Courthouse
Veteran’s Preference Request: Self Identification
430 Commercial Street
Form
Emporia, KS 66801
Pursuant to K.S.A. 73-201(c), Veterans shall be preferred for initial employment and first promotion
in the state government of Kansas, and in the counties and cities of this state, if competent to
perform such services. In the event an eligible veteran is not hired for a position in which he or she
has applied, notification will be sent within 30 days by certified mail or personal service.
To determine eligibility, please answer the following questions:
Yes/No I entered the armed forces before Oct. 15, 1976, and separated from the armed forces
under honorable conditions. I served i) on active duty during any war (official dates for war service
are 4/6/1917 – 7/ 2/1921 and 12/7/1941 – 4/28/1952); ii) during the period 4/28/1952 -
7/1/1955; iii) in any campaign or expedition for which a campaign badge or service medal has
been authorized; or iv) for more than 180 consecutive days since 1/31/1955 but prior to
10/15/1976, excluding an initial period of active duty for training under the “six month” reserve
or national program.
Yes/No I entered the armed forces on or after 10/15/1976 and separated from the armed forces
under honorable conditions and was awarded a service medal or campaign badge.
I separated from the armed forces under honorable conditions and have a disability certified by
the U.S. Dept. of Veterans Affairs as being service connected, have been issued the purple heart
by the U.S. government, or have been released from active service with a service-connected
disability.
Yes/No I am the spouse of a veteran who has a 100% service connected disability as determined
by the U.S. Dept. of Veteran Affairs.
Yes/No I am the spouse of a veteran who died while and as a result of service in the armed forces
and have not remarried.
Yes/No I am the spouse of a prisoner of war, as defined by K.S.A. 75-4364 and amendments
thereto.
If you marked “Yes” on any of the above questions and desire to use Veteran’s Preference, please
sign and date this form and submit to the Human Resource Department, along with a copy of your
DD214 form or the DD214 form of the veteran under which you qualify.
Name:____________________________________________
Signature:_________________________________________ Date:_________