UNIVERSITY OF CALIFORNIA: REQUEST FOR DUAL EMPLOYMENT (STAFF APPOINTMENTS ONLY) Please complete Sections I and II and submit this form to the Employment Manager, Human Resources. Note that before a salary commitment is made to the employee and prior to the commencement of the dual employment appointment, Section III must be completed by Human Resources and approved. Date:__________ Dual Employment Start Date: __________ Dual Employment End Date: __________ SECTION I EMPLOYEE/DEPARTMENT INFORMATION – Employee Name: ID #: FULL-TIME Department REQUESTING Department Dept Name: Dept Name: Title: Title: Job Code: Job Code: Grade: Step: Step: Pay Rate: Pay Rate: Appt Percentage: Appt Percentage: FLSA Status: Exempt Non-exempt FLSA Status: Exempt Non-exempt Bargaining Unit: Bargaining Unit: Dept Contact: Dept Contact: Business Justification for Dual Employment: Description of Duties: (or attach job description) non-exempt NOTE: All time worked over 40 in a standard workweek by a employee must be paid at the appropriate overtime rate by the department(s) in which the time was actually worked. SECTION II DEPARTMENT APPROVALS – Employee Signature: Date: Print Name: Full-time Dept Supervisor Signature: Date: Print Name: Full-time Dept Head Signature: Date: Print Name: Requesting Dept Supervisor Signature: Date: Print Name: Requesting Dept Head Signature: Date: Print Name: Other Signature: Date: Print Name: -OVER- UNIVERSITY OF CALIFORNIA: REQUEST FOR DUAL EMPLOYMENT (continued) SECTION III To be completed by Human Resources – Meets all dual employment criteria? YES No (For staff see PPSM 30, Section III.B.10.a-g) If not, please explain:
UNIVERSITY OF CALIFORNIA: REQUEST FOR DUAL EMPLOYMENT (STAFF APPOINTMENTS ONLY) Please complete Sections I and II and submit this form to the Employment Manager, Human Resources. Note that before a salary commitment is made to the employee and prior to the commencement of the dual employment appointment, Section III must be completed by Human Resources and approved. Date:__________ Dual Employment Start Date: __________ Dual Employment End Date: __________ SECTION I – EMPLOYEE/DEPARTMENT INFORMATION Employee Name: ID #: FULL-TIME Department REQUESTING Department Dept Name: Dept Name: Title: Title: Job Code: Job Code: Grade: Step: Step: Pay Rate: Pay Rate: Appt Percentage: Appt Percentage: FLSA Status: Exempt Non-exempt FLSA Status: Exempt Non-exempt Bargaining Unit: Bargaining Unit: Dept Contact: Dept Contact: Business Justification for Dual Employment: Description of Duties: (or attach job description) NOTE: All time worked over 40 in a standard workweek by a non-exempt employee must be paid at the appropriate overtime rate by the department(s) in which the time was actually worked. SECTION II – DEPARTMENT APPROVALS Employee Signature: Print Name: Date: Full-time Dept Supervisor Signature: Print Name: Date: Full-time Dept Head Signature: Print Name: Date: Requesting Dept Supervisor Signature: Print Name: Date: Requesting Dept Head Signature: Print Name: Date: Other Signature: Print Name: Date: -OVER- UNIVERSITY OF CALIFORNIA: REQUEST FOR DUAL EMPLOYMENT (continued) SECTION III – To be completed by Human Resources Meets all dual employment criteria? (For staff see PPSM 30, Section III.B.10.a-g) YES No If not, please explain:
Dual_Employment_Request_Form_0.docx