Fill and Sign the Outside Employee Form

Employee Information – Outside Work Approval Form Employee Name First Name Last Name Title Title Appointment Grade Executive Staff Administrative Staff Department Department Name Major Organization Organization Name Per Cent Time Full Time Part Time (per cent time %     ) Appointment Period 12 mos 10 mos 9 mos Other     mos Details of Outside Work Work is to be performed for: Name of Employer or Organization Dates that work will be performed From MM / DD / YR to MM / DD / YR or Indefinite Type of organization for which work is to be performed Private For Profit Non Profit Public Federal State Other Briefly describe the work that will be performed       When will work be performed Outside regular work hours During regular work hours If work will be performed during regular work hours I plan on requesting: Vacation Leave Leave without pay Temporary change in per cent time Permanent change in per cent time Will other company employees be involved in this work? Yes No If other company employees involved please identify them (use additional sheet if necessary. First Name Last Name , First Name Last Name Is the organization for which the work is to be performed one in which you, your spouse, significant other or your children: Yes No Own equity/stock or are a partner? Yes No Hold a management position? Yes No Participate in its ongoing operation? Yes No Conduct research of direct value to the organization? Date by which response to this request is needed MM / DD / YR _____________________________________________________________________________ Employee Signature Date Supervisor’s Name: First Name Last Name Phone:     -     -      Email Address:       @       Approval Recommended Approval Not Recommended ________________________________________________________________________________________ Supervisor’s Signature Date Departmental Unit Head: First Name Last Name Request Approved Request Not Approved ________________________________________________________________________________________ Signature Date