Application-Fill Out Online, Print, Sign and Return to Kansas Works

Have you ever been a members of the Kansas Public Employees Retirement System,Firemen's System or the Kansas School Retirement System? Yes NoIf yes, give name of retirement system and a full explanation including dates ofemployment under other system:Are you currently a member of a military reserve organization? Yes NoIf yes, explain:REFERENCESGive name, address, and phone number of three persons who have known you atleast one year.1. Name: Phone: ( )Address:City: State: Zip:2. Name: Phone: ( )Address:City: State: Zip:3. Name: Phone: ( )Address:City: State: Zip:IN CASE OF EMERGENCY, NOTIFY:Name: Phone: ( )Address:City: State: Zip:Relationship:I HEREBY CERTIFY THAT THE INFORMATION GIVEN IN THIS APPLICATION ISTRUE AND CORRECT. I UNDERSTAND THAT THE CITY OF INDEPENDENCE, KSMAY RESEARCH ALL STATEMENTS AND CLAIMS MADE ON THIS APPLICATIONAND MAKE REFERENCE CHECKS. IF RESEARCH SHOWS THAT FALSEINFORMATION WAS WILLFULLY GIVEN BY ME, IT SHALL BE CONSIDEREDSUFFICIENT CAUSE FOR REJECTION OR DISMISSAL.SIGNATURE:DATE:Page 3

OFFICIAL USE ONLYINTERVIEWED: Yes No Failed to show DATE:HIRED: Yes No DATE:DEPARTMENT:Job Service I.D. No.:Computer entry by:DEPARTMENT HEAD:City I.D. No.:Date entered: