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DISCLOSURE OF OUTSIDE EMPLOYMENT
In accordance with Louisiana Revised and Policies of Board of Supervisors for the University of
Louisiana System, each full-time employee of Louisiana Tech University must report any outside
employment for which a salary, retainer, fee, or other form of remuneration is paid. A separate disclosure
form is required for each outside employment activity reported. Should an additional outside employment
activity be initiated subsequent to the annual disclosure date, a separate form must be submitted at that
time. If no outside employment qualifies for disclosure, please fill Name, Department, Title or
Classification, state “none” in the blank for Full Name and Address of Outside Employer or Business, and
sign
and date the reverse side of this form.
Employee Name: ______________________________________________________________________
Title or
Department:_____________________________________ Classification:_________________________
Full Name & Address of any Employer or Business for Which You Have Received payment or Have an
Economic Interest: _____________________________________________________________________
_____________________________________________________________________________________
Time Commitment Inclusive Dates
Required:_______________________________________ of Activity: ___________________________
1. Describe the nature of the employment:_________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
2. Will this outside employment, combined with any other outside employment previously approved,
prevent or infringe upon performance of regularly assigned full-time duties? ________ If yes, please
explain:
_________________________________________________________________________________
_________________________________________________________________________________
3. Will this outside employment entail the utilization of university facilities, equipment, materials, or
involve other university employees or students? ________. If yes, please explain:
__________________________________________________________________________________
__________________________________________________________________________________
4. Will this outside employment involve an entity currently doing or actively seeking to do business
with your university department or administrative unit? _______. If yes, please explain:
__________________________________________________________________________________
__________________________________________________________________________________
5. Will this outside employment involve any other governmental entity ( local, state, federal,)? ________
If yes, please explain:
__________________________________________________________________________________
__________________________________________________________________________________
It is understood that: (1) I will not represent an outside employer of the university. (2) Any views I may
express on behalf of an outside employer do not necessarily reflect the views of the university. (3) The
name of the university and/or my official capacity at the university cannot in any way be used in support
of any position I may take in behalf of an outside employer.
It is further understood that I have disclosed outside employment in compliance with the provisions of
Louisiana Revised Statutes 42:1101 et seq. relative to outside employment, Louisiana Revised Statutes
42:61 et seq. relative to dual office holding and the policies on these subjects as defined in Louisiana
Tech University’ Policy # 1416, as well as the Rules
of the Board Supervisors for the University of
Louisiana System. Copies of these documents are available for review in the University Library, Office of
Human Resources, and in the offices of each Department Head and Dean.
Employee Signature: ________________________________________Date:_______________________
Dept. Head/Budget Unit Head: ________________________________Date:_______________________
Comments:___________________________________________________________________________
Academic Dean: ___________________________________________Date:_______________________
(if applicable)
Comments: ___________________________________________________________________________
All Signatures below this point will be obtained, if necessary, during the review process as required
by the Board of Supervisors
Appropriate Vice Pres.:_____________________________________ Date:________________________
(if applicable)
Comments: ___________________________________________________________________________
President:________________________________________________Date:________________________
(if applicable)
Comments:___________________________________________________________________________
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Completed 23 July 2020

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