Section 2 - Requesting Department Certification
Department:
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.
_____________________________________ _________________________
Supervisor Date
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.
_____________________________________ _________________________
Supervisor Date
_____________________________________ _________________________
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)
_____________________________________ _________________________
Employee Date
APPROVED:
Director of Human Resources Date
