Fillable INTERSESSION SECONDARY EMPLOYMENT NOTIFICATION FORM

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INTERSESSION SECONDARY EMPLOYMENT NOTIFICATION FORM

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Country of origin: US
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Page 1 of 2
Any bar
gaining unit employee with a regular work schedule of less than 52 weeks per year should complete this form to
report INTERSESSION SECONDARY EMPLOYMENT. Secondary employment is non-CPS employment for remuneraon.
This form may be completed electronically, but must be printed out and signed prior to submission.
INTERSESSION SECONDARY EMPLOYMENT NOTIFICATION FORM
CPS EMPLOYMENT INFORMATION
Complete these boxes with informaon relang only to CPS employment.
NAME
ADDRESS
WORK PHONE
CELL OR HOME PHONE
JOB TITLE
SCHOOL NAME/AREA OFFICE OR DEPARTMENT
DESCRIPTION OF DUTIES
WORK SCHEDULE:
Please specify start and end mes for each day (for example 8am - 5pm).
Mo
n __________ Tues__________ Wed __________ Thurs __________ Fri __________ Sat __________ Sun __________
Variable/Other Hours:
Please describe. ________________
SECONDARY EMPLOYMENT INFORMATION (Including Ownership/Partnership in any Business)
Complete these boxes with informaon relang only to secondary employment.
NAME OF EMPLOYER OR BUSINESS TYPE OF BUSINESS
ADDRESS OF EMPLOYER OR BUSINESS Is this address where you perform your dues? YES NO
If NO, Pleas
e provide the address where you perform your dues:
NAME OF SUPERVISOR
TITLE OF SUPERVISOR
DESCRIPTION OF DUTIES
WORK SCHEDULE: Please specify start and end mes for each day (for example 6pm - 8pm).
Mo
n __________ Tues __________ Wed __________ Thurs __________ Fri __________ Sat __________ Sun __________
Variable/Other Hours:
Please describe. _______________________________________________________________________________
Page 2 of 2
CPS EMPLOYEE CERTIFICATION OF COMPLIANCE
I, _________________________________, certify that this secondary employment does not conflict with any of the
duties or demands of my CPS employment.
EMPLOYEE SIGNATURE
DATE
PLEASE SUBMIT COMPLETED FORM BY U.S. MAIL, MAIL RUN, OR EMAIL TO:
Senior Policy Advisor
Chicago Public Schools
1 North Dearborn, Suite 900
Chicago, IL 60602
Mail Run 125
PL
EASE NOTE: Pursuant to Section XIII of the Code of Ethics, the Ethics Advisor reserves the right to reverse any
secondary employment approval that does not comply with the CPS Code of Ethics or any other statute that may apply.
bfcaminer@cps.edu
Please direct any questions regarding ethics review to Brian Caminer at (773) 553-1312 or bfcaminer@cps.edu.
Brian Caminer
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INTERSESSION SECONDARY EMPLOYMENT NOTIFICATION FORM

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Completed 26 April 2021

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