"Secondary Employment Authorization Request Form (Outside of State Government)" - Florida

This "Secondary Employment Authorization Request Form (Outside of State Government)" is a Florida-specific form released by the Florida Department of Juvenile Justice on December 1, 2011.

Download the form by clicking the link below, fill it out by hand, and mail it as per the guidelines provided by the department or the applicable legal instructions.

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Download "Secondary Employment Authorization Request Form (Outside of State Government)" - Florida

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FDJJ 1002.17-1
Attachment 1
STATE OF FLORIDA
Revised 12/11
DEPARTMENT OF JUVENILE JUSTICE
SECONDARY EMPLOYMENT AUTHORIZATION REQUEST
(OUTSIDE OF STATE GOVERNMENT)
Employee’s PF ID#:
DATE:
Supervisor Name:
TO:
Employee’s Name:
Class Title:
FROM:
Please Print or Type
SUBJECT: DJJ
Employment Authorization Request
Secondary
Request for Fiscal Year:
July 1, _______ through June 30, _________
Approval is valid ONLY for the fiscal year requested. To continue secondary employment from year to year, a new form must be
submitted prior to July 1 each year. The Supervisor may rescind approval. Secondary employment with a contract provider (business
entity) is prohibited if such employment violates the provisions of chapter 112, F.S. An employee is subject to disciplinary action, up to
and including dismissal, if he/she:
1.
fails to seek approval for secondary employment prior to commencing the secondary employment;
2.
fails to terminate secondary employment, when requested;
3.
works the secondary employment while on an approved sick leave from the Department; or
4.
works the secondary employment while receiving workers’ compensation benefits after authorization is suspended in accordance
with DJJ Policy 1002.
DJJ location at which you are employed:
DJJ Tel. No.:
(Name and Address)
__________________________________________________________________________________________________________
DJJ work days/hours: Days:
From:
AM/PM To:
AM/PM
Summarize your DJJ duties:
Name of Secondary Employer:
Address of Secondary Employer:
Name of Manager for Secondary Employer:
Tel. No.:
Title of Position: _______________________________________________________________
Give specific details of your secondary employment work duties:
Give your secondary employment work days/hours: Days:
From:
AM/PM To:
AM/PM
Does the secondary employer do business with DJJ? (Check one)
Yes
No
If you check yes, please explain:
Employee's Signature:
Date:
Supervisor Recommends:
Approved
Denied Signature:
Date:
Print Name:
Office of General Counsel:
No Conflict
Conflict
Potential Conflict
Refer to ELT Member for final determination.
Signature:
Date:
Approved
Denied Signature:
Date:
Final Agency Action:
Selected Exempt or Senior Management Service Employee
:
Send copies to:
1. Human Resources Liaison
2. Bureau of Human Resources, 2737 Centerview Drive, Tallahassee, FL 32399-3100
A
/
FTER APPROVAL
DENIAL
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FDJJ 1002.17-1
Attachment 1
STATE OF FLORIDA
Revised 12/11
DEPARTMENT OF JUVENILE JUSTICE
SECONDARY EMPLOYMENT AUTHORIZATION REQUEST
(OUTSIDE OF STATE GOVERNMENT)
Employee’s PF ID#:
DATE:
Supervisor Name:
TO:
Employee’s Name:
Class Title:
FROM:
Please Print or Type
SUBJECT: DJJ
Employment Authorization Request
Secondary
Request for Fiscal Year:
July 1, _______ through June 30, _________
Approval is valid ONLY for the fiscal year requested. To continue secondary employment from year to year, a new form must be
submitted prior to July 1 each year. The Supervisor may rescind approval. Secondary employment with a contract provider (business
entity) is prohibited if such employment violates the provisions of chapter 112, F.S. An employee is subject to disciplinary action, up to
and including dismissal, if he/she:
1.
fails to seek approval for secondary employment prior to commencing the secondary employment;
2.
fails to terminate secondary employment, when requested;
3.
works the secondary employment while on an approved sick leave from the Department; or
4.
works the secondary employment while receiving workers’ compensation benefits after authorization is suspended in accordance
with DJJ Policy 1002.
DJJ location at which you are employed:
DJJ Tel. No.:
(Name and Address)
__________________________________________________________________________________________________________
DJJ work days/hours: Days:
From:
AM/PM To:
AM/PM
Summarize your DJJ duties:
Name of Secondary Employer:
Address of Secondary Employer:
Name of Manager for Secondary Employer:
Tel. No.:
Title of Position: _______________________________________________________________
Give specific details of your secondary employment work duties:
Give your secondary employment work days/hours: Days:
From:
AM/PM To:
AM/PM
Does the secondary employer do business with DJJ? (Check one)
Yes
No
If you check yes, please explain:
Employee's Signature:
Date:
Supervisor Recommends:
Approved
Denied Signature:
Date:
Print Name:
Office of General Counsel:
No Conflict
Conflict
Potential Conflict
Refer to ELT Member for final determination.
Signature:
Date:
Approved
Denied Signature:
Date:
Final Agency Action:
Selected Exempt or Senior Management Service Employee
:
Send copies to:
1. Human Resources Liaison
2. Bureau of Human Resources, 2737 Centerview Drive, Tallahassee, FL 32399-3100
A
/
FTER APPROVAL
DENIAL
Save As
Reset/Clear Form
Print Form
Email Form
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