Concurrent Employment Information Form

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UNIVERSITY OF CENTRAL ARKANSAS
CONCURRENT EMPLOYMENT INFORMATION
NOTE: This form must be completed and attached to each Personnel Action Form
requesting appointment or change.
_____________________________________________________________________________________________
Name ______________________________ Employee ID No. _______________
CAUTION:
Under Arkansas Code 6-63-307 (b) Any employee knowingly violating the provisions of this section shall be
subject to immediate termination and shall be barred from employment by any agency or institution of the State of Arkansas for a
period of not less than three (3) years or until such employee shall repay to the State of Arkansas any sums received by such
employee in violation of this section, together with interest at a rate of ten percent (10%) per annum.
Will you be employed during the period of this PAF in any other roles or assignments with
UCA or with other State Agencies or Institutions? (Including additional teaching
assignments, part-time work and temporary project assignments.)
____ NO
If no, please provide signature and date below.
____ YES
If yes, please provide specific information below. Attach additional sheet if necessary.
Work location,
Employment
Work Schedule
Assignment
Dept/Employer
Period
Days/ Hours
Salary
Example:
1/13/05 – 5/06/05 T,Th 8 a.m.-1:00 p.m.
UCA Music
1/13/05 – 5/06/05 MWF 9-11 a.m.
UCA Music
$25,000
1/13/05 – 5/06/05 MWF 2-4 p.m.
UALR Music
$ 5,200
Please list your UCA teaching schedule as well as your concurrent employment schedule
.
I understand that concurrent employment must be approved by the State Office of Personnel
Management prior to my beginning employment.
Signature ________________________________ Date _______________
As Chair/Dean/Dept. Mgr., I acknowledge that I am aware that the above-mentioned person is employed elsewhere and that there
is no conflict with the assigned work schedule at UCA.
____________________________________________
______________________
Chair/Dean
Date

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