Request for Public Outside 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, another
public entity.
For approval for the above named Lamar State College - Port Arthur employee to participate in
employment/activity with another public entity.
Section III - Public Employer Information. Complete all boxes.
Outside Public Employment/Activity
Name of Em
ployer/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?
Eligible for FLSA Overtime?
Covered by Social Security?
Enrolled in Group Insurance?
Receive State Longevity Pay?
Receive State Hazardous Duty Pay?
Receive Benefit Replacement Pay?
Enrolled in Retirement Program?
Section V - Employee/Prospective Employee Statement. I hereby certify that the public 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 VI - Recommendations. Considering the benefits to the State, the requirements of State or Federal law, and the
potential for conflict with the employee's Lamar State College - Port Arthur duties and responsibilities, indicate your
recommendation regarding this request.
Department Head Signature:
Date:
Recommend Approval
Dean Signature: Date:
Recommend Approval
Section VII - Vice President's Decision.
Vice President Signature:
Date:
Routing: If approved for Purpose 1 above, Department Head sends original with hiring F3.2 through usual channels. If approved for Purpose 2 above,
forward original to Human Resources for placement in the employees personnel file.
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
TRS ORP Other
None
1.
2.
No
Yes
Yes
No
Yes
No
