Off Duty Employment Application
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1
2STATE OF NEW YORK, UNIFIED COURT SYSTEM
OFFICE OF COURT ADMINISTRATION
SUBMIT COMPLETED FORM TO:
ADMINISTRATIVE DIRECTOR
OFFICE OF COURT ADMINISTRATION
th
25 Beaver Street, 11
Floor, New York, NY 10004
APPLICATION FOR OFF-DUTY SECURITY EMPLOYMENT
PEACE OFFICER TITLES - ONLY
‘ New Application
‘ Renewal
Last Name
First Name
:
:
Contact Phone Number
( G Cell or G Home):
Contact Phone Number (
G
Work):
Present Assignment: ____________________________________________________
Title: ___________________________
(UCS Assignment: Court/Judicial District)
________________________
__________________
Phone: _______ ___ _
__
(UCS Assignment: Mailing Address)
Outside Employment: ____________________________________________
____
_
Title of Position: _________
__
(Name of Firm or Person)
____________________
__________________
(Employer’s Address)
(Street)
(City)
(County)
(State) (Zip Code)
___________________________________________________________________________________
Describe Type of Business (Provide NYS License # if Guard Service)
“
“
Firearm Required
Firearm Not Required
Exact Location(s) of Employment: ______________________________________________________________________
(Name and Address of Company or Individual to be Guarded)
Describe Specific Duties and Responsibilities:
employee’s Signature:
Date:
PRIOR APPROVAL IS REQUIRED BEFORE STARTING OFF-DUTY EMPLOYMENT
FOR OCA USE ONLY
______________
LOG REFERENCE #
DATE RECEIVED:
THIS REQUEST FOR OFF-DUTY EMPLOYMENT IS:
‘ APPROVED / ‘ DENIED
_________________________________________________
SIGNATURE - ADMINISTRATIVE DIRECTOR, OCA
DATE
REVISED 7/2011
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