Supplementary employment request



Download 35.05 Kb.
Date06.02.2017
Size35.05 Kb.

COMMONWEALTH OF PENNSYLVANIA

STD355 Rev. 2-02

SUPPLEMENTARY EMPLOYMENT REQUEST




Complete all items and mail directly to your department's human resources officer within 10 working days of receiving this request form.

QUESTIONS I THROUGH 6 PERTAIN TO COMMONWEALTH EMPLOYMENT WITH YOUR DEPARTMENT.

I. EMPLOYEe’s NAME

EmploYee NO.

     

     

2. MAILING ADDRESS

     

3. PRESENT CLASS TITLE

AGENCY/BUREAU

WORK SITE

     

     

     

4. BRIEFLY OUTLINE YOUR JOB DUTIES*

     

5. IN YOUR DEPARTMENTAL JOB DUTIES, DO YOU:

  1. PARTICIPATE IN THE NEGOTIATION OF OR DECISION TO
    AWARD CONTRACTS, OR OTHERWISE TAKE OR RECOMMEND
    OFFICIAL ACTION OF A DISCRETIONARY NATURE WITH RE-
    GARD TO CONTRACTING OR PROCUREMENT?

 YES

 NO

F. TAKE OR RECOMMEND OFFICIAL ACTION OF A DISCRETIONARY
NATURE WITH REGARD TO INSPECTING, LICENSING, REGULA-
TING OR AUDITING ANY BUSINESS, INDIVIDUAL, CORPORATION,
UNION, ASSOCIATION, FIRM, PARTNERSHIP, COMMITTEE,
CLUB OR OTHER ORGANIZATION OR GROUP OF PERSONS?


 YES

 NO

  1. PARTICIPATE IN THE SETTLEMENT OF CLAIMS OR
    CHARES IN A CONTRACT?




 YES

 NO

  1. PARTICIPATE IN THE GRANTING OF SUBSIDIES OR OTHER

WISE TAKE OR RECOMMEND OFFICAL ACTION OF A
DISCRETIONARY NATURE WITH REGARD TO THE ADMINISTRATION

OR MONITORING OF GRANTS OR SUBSIDIES?



 YES

 NO

  1. PARTICIPATE IN THE MAKING OF LOANS?




 YES

 NO










  1. PARTICIPATE IN THE FIXING OF RATES?




 YES

 NO

H. TAKE OR RECOMMEND OFFICIAL ACTION OF A
DISCRETIONARY NATURE WITH REGARD TO PLANNING
OR ZONING?


 YES

 NO

  1. PARTICIPATE IN THE ISSUANCE OF PERMITS, CERTIFI
    CATES, GUARANTEES OR OTHER THINGS OF VALUE?




 YES

 NO










IF THE ANSWER TO ANY PART OF QUESTION 5, ABOVE, IS "YES". PLEASE DESCRIBE THE DUTIES FOR EACH QUESTION ANSWERED “YES”.*

     

6. DAYS WORKED**

APPROX. START TIME

APPROX. STOP TIME

(CIRCLE) SU M TU W TH F SA

     

     

QUESTIONS 7 THROUGH 13 PERTAIN TO REQUESTED SUPPLEMENTARY EMPLOYMENT INCLUDING SELFEMPLOYMENT.

7. NAME OF COMPANY OR ORGANIZATION

     

8. ADDRESS OF COMPANY OR ORGANIZATION

     

9. TYPE OF BUSINESS IN WHICH THE COMPANY OR ORGANIZATION IS ENGAGED

     

10. TITLE OF POSITION FOR WHICH YOU ARE APPLYING

DATE YOU APPLIED FOR POSITION

DATE YOU EXPECT TO COMMENCE SUPPLEMEN-
TARY EMPLOYMENT

     

     

     

11. BRIEFLY DESCRIBE THE DUTIES OF THE POSITION APPLIED FOR WITH THE COMPANY OR ORGANIZATION*

     

12. ANSWER (A) AND (C) OR (B) AND (C), WHICHEVER IS APPLICABLE TO YOUR PROPOSED SUPPLEMENTARY EMPLOYMENT.

  1. TO THE BEST OF YOUR KNOWLEDGE AND BELIEF, DOES

THE COMPANY OR ORGANIZATION WITH WH ICH YOU ARE
APPLYING FOR A POSITION ENGAGE IN ANY BUSINESS OR
ACTIVTY WHICH COULD POSSIBLY BE RELATED TO
YOUR DEPARTMENTAL DUTIES, OR WHICH COULD POSSIBLY
CREATE AN ACTUAL OR APPARENT CONFLICT WITH YOUR
DEPARTMENTAL DUTIES? (IF YES. EXPLAIN TO THE BEST
OF YOUR KNOWLEDGE.*)

OR

 YES

 NO

C. IS THIS ORGANIZATION ASSOCIATED WITH A POLITICAL
SUBDIVISION OR IS IT A POLITICAL SUBDIVISION OF
THE COMMONWEALTH OF PENNSYLVANIA; IS THE ORGAN-
IZATION ASSOCIATED WITH AN AGENCY OF THE GOVERN-
MENT OF THE UNITED STATES OF AMERICA? (IF YES,
EXPLAIN TO THE BEST OF YOUR KNOWLEDGE.*)

 YES

 NO

B. TO THE BEST OF YOUR KNOWLEDGE AND BELIEF, WOULD
YOUR SELF-EMPLOYMENT INVOLVE YOU IN ANY BUSINESS
OR ACTIVITY WHICH COULD POSSIBLY BE RELATED TO
YOUR DEPARTMENTAL DUTIES, OR WHICH COULD POSSIBLY
CREATE AN ACTUAL OR APPARENT CONFLICT WITH YOUR
DEPARTMENTAL DUTIES (IF YES, EXPLAIN TO THE BEST
OF YOUR KNOWLEDGE.*)

 YES

 NO










AND








13. DAYS WORKED**

NO. OF HOURS PER WEEK

(CIRCLE) SU M TU W TH F SA

     










APPROX. START TIME

APPROX.STOP TIME

     

     

* ATTACH AN 8 1/2 X 11 SHEET IF ADDITION SPACE IS NEEDED. (LIMITED SPACE IS PROVIDED ON REVERSE SIDE OF THIS FORM.)

** IF YOU WORK AN IRREGULAR, VARIABLE OR ROTATING SHIFT, SO INDICATE AND SHOW FOR A TWO-WEEK PERIOD THE VARIATIONS IN YOUR SHIFTS AND/OR IN THE STARTING AND STOPPING TIMES.

(CONTINUED ON REVERSE SIDE)

14. I do solemnly swear (or affirm) that this application contains no misrepresentations, falsifications, omissions or concealment of


material facts, and that the information contained herein is true and complete to the best of my knowledge and belief. I under-
stand that should any of the information set forth in questions 5 through 13 change, I must submit a new Supplementary Employ-
ment Request Form.

____________________________________________________________________________

(EMPLOYEE’S SIGNATURE)

__________________________________________________

(DATE)


15. Approval or disapproval of your Supplementary Employment Request will normally be given by your department within 15 working


days of the receipt of your request by your department's human resources office. If your department needs additional information con-
cerning your request, a representative of your department's human resources office will contact you about providing this additional
information. After receipt of any such additional information, your department will promptly approve or disapprove your request.
16. If your department disapproves your Supplementary Employment Request, you may request a review of the disapproval by sending a
written Request for Review of the disapproval to the Secretary of Administration within 10 working days of the issuance of the
disapproval by your department. Request for Review forms will be available from your human resources office. The Secretary of
Administration shall normally respond to the Request for Review of the disapproval within 30 calendar days of the receipt of the
request. If the Secretary of Administration needs additional information concerning your request, a person designated by the
Secretary of Administration will contact you about providing this additional information. After receipt of any such additional
information, the Secretary of Administration will promptly either approve your Request for Supplementary Employment or will
concur in the disapproval given by the Department.
17. Approval of the Secretary of Administration is required for the following:


  1. Supplementary employment for all senior level positions as defined in Management Directive 515.16, Appointment to Senior Level Positions, and

  2. Supplementary employment involving political activity, with or without compensation or remuneration.

Approval of supplementary employment requests for employees in senior level positions and supplementary employment requests

involving political activity shall be forwarded to the Secretary of Administration for review within 10 working days of receipt from an

agency. The Secretary of Administration will review the requests to determine whether the request is consistent with the employee’s

departmental duties and responsibilities; with the public interest; with the public’s perception of state government; and whether the

request is otherwise appropriate.



USE THIS SPACE FOR FURTHER EXPLANATIONS FOR QUESTIONS 4, 5. 11 AND 12.



Share with your friends:


The database is protected by copyright ©dentisty.org 2019
send message

    Main page