PeopleSoft User Affiliate Form

* Email address of person completing this form:

Sex:   Male      Female

Birth Month and Day
(ex. 0406):

* 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