Directions
1. Enter your name, department name for your primary position, and the name
of your Administrative Supervisor for your primary position.
2. Select ONLY the category of your primary position at LCC.
3. Complete grid, disclosing relevant employment external to the College
(whether full-time, part-time, contract, or self-employment) and average
hours worked per week in each position. Outside work is relevant if (a) it
involves goods or services that are similar or related to, or competitive with,
those offered by LCC; (b) it involves goods or services of the kinds purchased
or used by LCC or its students; (c) it potentially limits your availability to
perform your work for LCC; or (d) it potentially conflicts with your other
obligations to LCC (e.g., concerning Intellectual Property, confidentiality,
fiduciary status, etc.).
4. Sign and date form. Electronic signatures are accepted.
5. Save the completed PDF as a new file.
6. Email the new file to your Administrative Supervisor and
HR-Support@star.lcc.edu.
Name _________________________________ Department_______________
Administrative Supervisor _____________________________________________
Primary Position Category at LCC:
Faculty Administrator Support Safety Maintenance
