Date: Attention: President of Chiba University Name of Representative: (Seal) Name of Organization: We wish to request the additional service of a staff member of your university as stated below and hereby seek your approval. We agree to the disclosure on your university’s website of the name of our organization, the amount of remuneration to be provided, the name of the diagnosis or treatment department of the staff member to be assigned, and other details required by your university. Name, position and department of Name: Position: the person to undertake the Department: 1 additional service at Chiba University 2 Title of service requested 3 Details of service requested □ From _______ [mm/dd/yy] to _______ [mm/dd/yy] Duration of service No longer than 1 year in □ Date of approval: _______ [mm/dd/yy] principle; 4 years maximum 4 when a term of office is established by law, etc,. □ Frequency/hours of service ___ days, ___ hours per day, during ____ (state period such as week, 8 hours a week as maximum. month, year) □ (Excluding the hours of service Weekly on ______ (state day or days) from _____ o’clock to ____ 5 during weekends and public o’clock (state hours) □ holidays) Intensive lectures: ____ hours □ Other ( )
Date: Attention: President of Chiba University Name of Representative: (Seal) Name of Organization: We wish to request the additional service of a staff member of your university as stated below and hereby seek your approval. We agree to the disclosure on your university’s website of the name of our organization, the amount of remuneration to be provided, the name of the diagnosis or treatment department of the staff member to be assigned, and other details required by your university. 1 Name, position and department of the person to undertake the additional service at Chiba University Name: Position: Department: 2 Title of service requested 3 Details of service requested 4 Duration of service No longer than 1 year in principle; 4 years maximum when a term of office is established by law, etc,. □ From _______ [mm/dd/yy] to _______ [mm/dd/yy] □ Date of approval: _______ [mm/dd/yy] 5 Frequency/hours of service 8 hours a week as maximum. (Excluding the hours of service during weekends and public holidays) □ ___ days, ___ hours per day, during ____ (state period such as week, month, year) □ Weekly on ______ (state day or days) from _____ o’clock to ____ o’clock (state hours) □ Intensive lectures: ____ hours □ Other ( )