Approvalisrequestedtoengageinthefollowingoutsideemployment Activity

CONSULTINGANDPAIDPROFESSIONALSERVICEAPPLICATIONFORM

A.CurrentEmploymentInformation

FirstNameMiddleNameLastName

DepartmentJobTitle

Employee ID:Location(Checkone):UHUHCLUHDUHV

B.ProposedOutsideEmployment

Approvalisrequestedtoengageinthefollowingoutsideemployment activity:(Checkoneofthefollowing.Ifrequestingapprovalfor morethanone activity, please use asecondform.)

MultipleEmployment-WorkperformedforaseparatestateagencyoranothercomponentuniversityoftheUniversityofHoustonSystem(“System”). Ifchecked,indicate whichapplies:

Workperformedforanothercomponentof theUHSystem.(Example:UHfacultyteachingasadjunct atUHD.)

WorkperformedforastateagencythatisnotacomponentuniversityoftheSystem. (Example:UHDfacultyworkingpart-timefor the TexasHigher EducationCoordinatingBoard.)

Consultingandotheroutsideemployment-Activitiesundertakenforremunerationfromathirdpartywheretheactivityiswithinthescopeofactivities,functionsorexpertiseforwhichtheindividualiscompensatedbytheSystem.(Example:UHVAccountsPayableCoordinatorworkingforH&RBlockduringthespringmonthsorUHCLfacultyteachingasadjunctatTexasStateUniversity.)

AthleticallyRelatedEmployment-Intercollegiateathleticsdepartmentsmustprovideathleticallyrelatedincomeandbenefitsfromsourcesoutsidethecomponentuniversity.(Example:UHAssistantBasketballCoachworkingatasummerbasketball clinic forinner city youth.)

C.InformationRegardingEmployingFirmorIndividual

Firm/Individual

StreetAddressCityStateZipCode PhoneNatureofproposedwork.

Justification.HowdoesthisactivitybenefittheUniversityofHoustonSystem?

Proposedtimeperiod

StartDateEndDate

Estimatedhoursfortheproposedactivity(perday,perweekandtotal).

Willanyhourscoincidewithnormalworkinghours?

YesNoIfso,howmany?

Isanequityownershipinvolved?YesNo

Ifso,describetheamountandtypeinterestownedortobeownedandanyconditionstothatownershipinterest.

Describe the extent to which University facilities, space, equipment or support staff are to be used. WhatcompensationisproposedtotheUniversityforsuchuse?

D.Agreement

Icertifythattheaboveinformationsubmittedbymeistrueandcompletetothebestofmyknowledge.IherebygrantpermissiontotheUniversity ofHoustonSystem toverifyinformationprovidedbymeregardingmyoutsideorconsultingemployment.IacknowledgethatIhavereadandagreetoabidebythepoliciesreferencedbelow.Furthermore,Iacknowledge thattheseactivities donotcreateaconflictofinterest orcommitmentwithmyUniversityresponsibilities,norwilltheyadverselyaffectorimpairmyindependenceorjudgmentintheperformanceofmyUniversityduties.IunderstandthatifthisactivityextendspastAugust31st,annualre-approvalisrequired.

SignatureDate

UniversityofHoustonSystemAdministrativeMemorandum02.A.08,ConsultingandPaidProfessionalServiceUniversityofHoustonSystemAdministrativeMemorandum02.A.09,ConflictofInterest

E.Approvals

Signature(Employee'sSupervisororChair)

ApprovedDisapproved

Date

Signature(DepartmentHeadorDean)

ApprovedDisapproved

Date

Signature(DivisionHead)

ApprovedDisapproved

Date

PleasesubmitthefullyexecutedformtoyourHuman Resourcesdepartment.