Employee Name (Last, first, middle) 2. Position Title

Date of Hire 4. Supervisor Name 5. KSU Work Schedule: ☐F/T ☐P/T ☐Intermittent ☐Temp ☐ Seasonal☐ Other

Are you now engaged in any outside employment? ☐Yes ☐No (If yes, explain. Attach additional sheet if necessary)

Prospective Employer's Name and Address 8. Type of Business 9. Proposed Work Schedule (Days/Hours)

Proposed Start and Ending Date:

Describe the Outside Employment or Business Activity (Use Additional Sheets if Necessary)

I hereby certify that the statements made in this Section are complete and correct to the best of my knowledge.

Employee Signature Date

Section 2 - Recommendations of Supervisory Officials

Receipt of Initial Request: B. Receipt of a fully Completed Request: C. Deadline for Approval/Disapproval Date:

Date: Date:

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.