Federal Privacy Act Disclosure Section 7(a)(2)(B) þ þ (give beginning and ending dates if a series): þ YES NO þ Applicant printed name þ Signature þ Date Accidental Injury, Repetitive Trauma or Occupational Disease First Middle Last Male FemaleSocial Security number: þ Street: þ Phone: Email: DO NOT WRITE IN THIS SPACE DO NOT WRITE IN THIS SPACEAPPLICATION FOR BENEFITSwww.dol.ks.gov