Request for Private Employment/Activity
Instructions: One form is required for each outside employment/activity. Approval is required before accepting
an outside employment activity. Approvals expire at the end of the outside employment/activity.
Section I - Name: EID#:
Section II - Purpose. Check the appropriate box.
For approval to hire the above named person who is employed by, or involved with the activities of, a
private entity.
For approval for the above named Lamar Port Arthur employee to participate in employment/activity with a
private entity.
Section III - Private Employer Information. Complete all boxes.
Outside Private Employment/Activity
Name of Employer/Activity:
Address of Employer/Activity:
Phone# of Employer/Activity:
Department Name:
Job Title:
Duties/Responsibilities:
Begin/End Date:
% of Appointment/Hours per week:
Receiving Compensation?
Section IV - Employee/Prospective Employee Statement. I hereby certify that the private employment/activity reported
above does not constitute a conflict with my Lamar State College - Port Arthur duties and responsibilities. I understand
and agree that Lamar State College - Port Arthur may lawfully require me to end the employment/activity if it is
determined to be in conflict with my Lamar State College - Port Arthur duties and responsibilities.
Employee/Prospective Employee Signature: Date:
Section V - Department Head Review. Select one of the following statements:
In my judgement the private employment/activity described above is not in conflict with the
employee's Lamar State College - Port Arthur duties and responsibilities. The request is approved.
In my judgement the private employment/activity described above may be in conflict with the
employee's Lamar State College - Port Arthur duties and responsibilities. I am forwarding the request for
further administrative review.
Department Head Signature:
Date:
Section VI - Administrative Review and Decision.
Dean/Division VP Signature:
Date:
Routing: Original to Human Resources for placement in the employees personnel file.
1.
2.
Yes
No
1.
2.
Approved
Not Approved
