Section 2 - Requesting Department Certification
Overload Assignment: (Describe duties and responsibilities)
SCHEDULE: (Specify hours and dates when work is to be performed)
COMPENSATION: (Specify rate of pay and total compensation for this assignment)
$ ___ per___ ____ up to a total $___________
I certify that services of a contractual employee are unavailable for the above assignment.
Section 3 - Employee’s Primary Supervisor Certificate
I certify that release time is not feasible for the above overload assignment and that the assignment involves no
conflict of interest or commitment with the employee’s primary regular employment.
Vice President/President Date
Section 4 - Employee Certification
I certify that the performance of the above overload assignment will not coincide with the work hours of
my primary regular employment. During the current fiscal year, I have performed the following overload
assignments: (Specify dates and total compensation received)
Director of Human Resources Date