Fillable Request to Engage in Outside Employment or Self-Employment (Office of Innovation and Technology)

Fill Online, Printable, Fillable, Blank Request to Engage in Outside Employment or Self-Employment (Office of Innovation and Technology) Form

Use Fill to complete blank online OFFICE OF INNOVATION AND TECHNOLOGY (PA) pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

Request to Engage in Outside Employment or Self-Employment (Office of Innovation and Technology)

On average this form takes 14 minutes to complete

The Request to Engage in Outside Employment or Self-Employment (Office of Innovation and Technology) form is 2 pages long and contains:

  • 3 signatures
  • 13 check-boxes
  • 38 other fields

Country of origin: US
File type: PDF

U.S.A. forms for Office of Innovation and Technology

BROWSE OFFICE OF INNOVATION AND TECHNOLOGY (PA) FORMS

Related forms
Fill has a huge library of thousands of forms all set up to be filled in easily and signed.
Fill in your chosen form
Sign the form using our drawing tool
Send to someone else to fill in and sign.
find another form
 
Request to Engage in
Outside Employment or
Self-Employment
City of Philadelphia
Department/Agency/Offi ce:
Date of Request:
Department No.:
To Be Submitted to Departmental Human Resources Manager
Last Name:
First Name Payroll Number:
Years of Service:
Class or Job Title:
Division or Unit:
Name of Supervisor:
Regular Hours and Days Worked at City:
For Uniformed Personnel Only:
Only complete information applicable to position.
Rank:
Badge #: District:
Platoon:
I am no longer engaged in approved outside employment or self-employment. End Date of Outside Employment or Self-Employment: ___________
I am currently engaged in approved outside employment or self-employment and wish to change the details of that employment (e.g., different
employer, hours of work) as described below.
I wish to enter into outside employment or self-employment as described below.
Please choose one of the following options:
Space is provided for one outside employment or self-employment request.
If you are seeking permission to work at more than one outside employment or self-employment, you must submit a separate form for each request.
Will your outside employment or self-employment be performed outside of your regular City
work hours? Yes No If No, please explain:
Regular Hours and Days Sought to Work:
E-mail of Supervisor (if applicable): Telephone:
Nature of Business:
Zip Code: State: City:
Address:
Name of Outside Employer:
List ownership or management interest in any business entity.
Does your proposed employer or you, if seeking self-employment, have contracts with or receive fi nancial assistance from the City of Philadelphia or any other governmental
entities? Do you anticipate contracts or fi nancial assistance will be sought? (If so, please describe in detail. If uncertain, ask this question of your prospective outside employer.)
Does your proposed outside employment or self-employment require you to personally engage in any transactions with the City of Philadelphia or with other governmental
entities? (If so, please describe in detail)
Is this work dangerous, hazardous, exhausting or otherwise potentially injurious to your health or safety?
(If yes, explain, and include any occupational hazards connected with the job.)
Describe in detail the duties you will perform for this employer or for yourself, if self-employed:
82-366 Int.
READ THE FOLLOWING STATEMENT CAREFULLY BEFORE SIGNING
I am requesting permission of my Appointing Authority or their designee to engage in the outside employment
or self-employment described in this Form. I have thoroughly reviewed the Mayor’s Executive Order 12-16
on Outside Employment and Self-Employment, as well as any policies of my department, agency or offi ce
concerning such employment. I understand that I may not engage in outside employment or self-employment
that is incompatible with my offi cial duties with the City of Philadelphia. Specifi cally, this outside employment or
self-employment must not:
1. bring disfavor or disrespect upon me; my department, agency or offi ce; or the City;
2. impede, or adversely affect my performance and proper discharge of my City duties;
3. shall not be arduous, strenuous, laborious, dangerous or exhausting;
4. make use of any City-owned or leased resources, including but not limited to telephones, Blackberries, vehicles,
printers, computers, or other supplies or equipment;
5. occur during the time I am being paid for or am conducting City work;
6. be another offi ce or a position of profi t with other governmental agencies, except as provided in Section 8-301 of
the Home Rule Charter;
I further understand that I shall not perform outside work while receiving sick leave or injury benefi ts from the City. If I
become injured, disabled or ill as a result of my outside employment or self-employment, I shall not be given paid sick leave
or injury benefi ts by the City.
I further understand that approval of my outside employment or self-employment does not alter or affect, in any way,
my obligation to comply with Chapter 20-600 of the Philadelphia Code (Standards of Conduct and Ethics), Title X of the
Philadelphia Home Rule Charter (Prohibited Activities), and, if applicable to me, the Pennsylvania Public Offi cial and
Employee Ethics Act, codifi ed at 65 Pa.C.S. 1101, et. seq. I further understand that I am required to disclose outside sources
of income of all annual fi nancial disclosure statements I am obligated to fi le.
I further understand that I have a continuing obligation to notify the Human Resources Manager or Designee of my
department, agency or offi ce if the information included on this Form should change, including if I am no longer engaging in
outside employment or self-employment, within 14 days of such change.
The information about my outside employment or self-employment that I have entered above is true and complete to the
best of my knowledge and belief.
Signature: ______________________________________________ Date of Request: ____________________
Attendance & Performance Review (To be completed by the Human Resources Manager or Designee)
82-366 Int. (Reverse)
Is Offi cer or Employee on Sick Abuse List: Yes No
Number of Sick Days (paid and unpaid) used in past 12 months:
Last Overall Performance Evaluation (if applicable):
Has Offi cer or Employee Received any discipline in last 12 months? Yes No (If yes, attach copies)
Recommendation: Approved Denied
Supervisor’s Name____________________________________________________
Supervisor’s Signature__________________________________ Date_____________________
Final Decision: Approved Denied
Appointing Authority or Designee’s Name_____________________________________
Appointing Authority or Designee’s Signature__________________________________ Date_____________________
If Denied, Reason for Denial:
click to sign
signature
click to edit
click to sign
signature
click to edit
click to sign
signature
click to edit
Download
Save PDF to desktop
Email
Email completed PDF
Send for Signing
Email for others to sign
Print
Print document
Choose a Field
Click on a field and
select the person that should complete it
Want to add a signature?
You can add a signature field
and assign it to someone else
to sign
Choose a Field
Click on a field and
select the person that should complete it

Request to Engage in Outside Employment or Self-Employment (Office of Innovation and Technology)

This document is locked as it has been sent for signing.

You have successfully completed this document.

Other parties need to complete fields in the document. You will recieve an email notification when the document has been completed by all parties.

This document has been signed by all parties.

Completed 14 July 2020

Message

View Audit Log
Print With Audit Log
Duplicate Document