Employee:______________________________________________________ Employee Number:________________________
Name of Secondary Employer:___________________________________________________________________________________
Secondary Employment Title:_______________________________________ Effective Date:____________________________
Description of Secondary Employment Duties/Responsibilities:_________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
Employee Statement of Compliance: This secondary employment (a) does not interfere with the performance of other responsibilities
as a System employee; (b) is limited in time; (c) is compatible with the interests of Lurleen B. Wallace Community College; and (d) does
not require use of institutional resources or facilities. This secondary employment will not (a) disrupt or interfere with the normal
operations of the College; (b) directly compete with the College; (c) impose additional financial operations burden upon the College;
(d) violate the Alabama Code of Ethics for public employees as set forth in the Code of Alabama; or (e) be of a nature such that the
outside employment would tend to decrease the effective performance of my College employment duties.
______________________________________________________________ _______________________________________
Employee Signature Date
Review of the submitted Notification of Secondary Employment form by the supervisory chain of command indicates that this
potential secondary employment does not constitute a conflict of interest.
_____________________________________________________________ _______________________________________
Reviewed By: Immediate Supervisor Date
_____________________________________________________________ _______________________________________
Reviewed By: Dean/Vice President Date
_____________________________________________________________ _______________________________________
Reviewed By: Human Resources Coordinator Date
_____________________________________________________________ _______________________________________
Reviewed By: President Date
If the secondary employment is believed to represent a conflict of interest, explain why: ____________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
cc: Employee
Human Resources
Immediate Supervisor Revised May 2017
NOTIFICATION OF SECONDARY EMPLOYMENT
Directions: In compliance with the Lurleen B. Wallace Community College policy, an employee is required to complete the Notification of
Secondary Employment form and submit the form to his/her immediate supervisor for review and approval prior to entering into an agreement of
secondary employment. Secondary employment is the term used to describe any additional employment in which a College employee is engaged
outside of Lurleen B. Wallace Community College and it may be paid or unpaid employment. It is the responsibility of the employee to notify the
College by submitting a revised Notification of Secondary Employment form if the status of previously approved secondary employment changes.
