REQUEST FOR SECONDARY EMPLOYMENT

Date: ___________________________

To:                               Ethics Commission

From:                            ________________________________________

Supervisor:                    ________________________________________

Ethics Coordinator:        ________________________________________

SUBJECT: Request for Permission to engage in secondary employment pursuant to Public Ethics Law § 15-502, I am submitting my request to engage in secondary employment.

1. Identifying Information:

Name ____________________________________  State Position & Grade __________________

Department _______________________________    Office Phone No. _______________________

Agency __________________________________    No. of years with State __________________

2. Brief description of duties and responsibilities in State position: _________________________

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3. Brief description of function of State Department/Agency in which you are employed:  ______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

4. Proposed Outside Employer:

Name of Entity: _________________________________________ Phone No. ___________________

Supervisor’s Name and Title: ___________________________________________________________

Address: ___________________________________________________________________________

  ___________________________________________________________________________

Brief description of Business Conducted by Entity: ___________________________________________

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5.  Position title, duties and responsibilities of secondary employment: _____________________

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6.  Hours per week to be spent with secondary employment and work schedule (specific hours of work for secondary employer): _____________________________________________________

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7.  Anticipated duration of secondary employment (temporary or permanent – months or years):_________________________________________________________________________

8. Special license or equipment required for secondary employment:______________________

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9.  Does the entity do any business with, or is it regulated by, your Department/Agency (explain): _____________________________________________________________________________________

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                                                                                    _________________________________________

                                                                                    Employee Signature

Recommendation of Department Head:

                        _______Approve

                        _______Disapprove (state specific reasons for denial)

Comments: ____________________________________________________________________

________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

___________________________________________

Signature of Department Head and Date

___________________________________________

Printed Name of Signator

REQUEST WILL NOT BE CONSIDERED UNLESS CURRENT

POSITION DESCRIPTION IS ATTACHED.