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