OUTSIDE EMPLOYMENT OR BUSINESS ACTIVITY REQUEST

Kentucky State University

Section 1 - To be completed by employee

  1. Employee Name (Last, first, middle) 2. Position Title
  2. Date of Hire 4. Supervisor Name 5. KSU Work Schedule: ☐F/T ☐P/T ☐Intermittent ☐Temp ☐ Seasonal ☐Other
  3. Are you now engaged in any outside employment? ☐Yes ☐No (If yes, explain. Attach additional sheet if necessary)
  4. Prospective Employer's Name and Address 8. Type of Business 9. Proposed Work Schedule (Days/Hours)
  5. Proposed Start and Ending Date:
  6. Describe the Outside Employment or Business Activity (Use Additional Sheets if Necessary)
  7. I hereby certify that the statements made in this Section are complete and correct to the best of my knowledge.
  8. Employee Signature Date
  9. Section 2 - Recommendations of Supervisory Officials
  10. Receipt of Initial Request: B. Receipt of a fully Completed Request: C. Deadline for Approval/Disapproval Date:
  11. Date: Date:
  12. In considering this request for outside employment or business activity, I have reviewed the Kentucky State University Employee and/or Faculty Handbooks, Conflict of Interest Policy and the Code of Conduct/Ethics policies and understand the employees' responsibilities and obligations to the University. My recommendation is made in accordance with those provisions.

Immediate Supervisor: ☐ Approval ☐ Disapproval

(Signature and Title) (Date)

Vice President: ☐ Approval ☐ Disapproval

(Signature and Title) (Date)

General Counsel: ☐ Approval ☐ Disapproval

Copies: Official Employee File, Employee, Supervisor