Veterans Preference Request: Self Identification Form printable pdf download

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:_________

Veterans Preference Request: Self Identification Form