Request for Outside Employment Approval

Date: _____________________

Employee name: ____________________________

Department: ________________________________

Title: ______________________________________

I hereby request approval to engage in outside employment as described below:

Nature of employment: ______________________________________________

Time required for employment: ________________________________________

I understand that [Company Name] policy forbids me from engaging in any form of outside employment or business opportunity, for myself or another employer, which would conflict or interfere with my job, especially while on company time. Additionally I understand that using company equipment or materials for outside employment is strictly prohibited. I understand that in order to engage in outside employment, I must receive approval from my supervisor and department director in advance of performing such outside employment, and that the approval may be withdrawn at any time.

I understand that failure to comply with the policy could result in disciplinary action up to and including termination of employment.

__________________________     _______________

Employee signature                            Date

DEPARTMENT DIRECTOR ACTION

__Request Approved __Request Denied

Comments or Special Conditions: ________________________________________

___________________________________________________________________

_________________________               _______________

Department director signature                   Date

Forward completed form to the Human Resource Department.