NEVADA DEPARTMENT OF CORRECTIONS
REQUEST FOR SECONDARY
EMPLOYMENT
NAME:
______________________________________________________ DATE: _______________
TITLE: ________________________________ INSTITUTION: _____________
B/A #: __________
PROPOSED SECONDARY
EMPLOYMENT:
______________________________________________
BUSINESS ADDRESS:
________________________________________________________________
_____________________________________________________________________________________
BUSINESS PHONE:
__________________________________________________________________
SPECIFIC ACTIVITY, BUSINESS,
OR
_____________________________________________________________________________________
PROPOSED DUTIES,
RESPONSIBILITIES, OR ACTIVITIES:
_______________________________
_____________________________________________________________________________________
ESTIMATED NUMBER OF WORKING
HOURS AT SECONDARY EMPLOYMENT:
____________
PROPOSED WORKING HOURS: ___________________a.m./p.m.
TO __________________a.m./p.m.
I UNDERSTAND THAT MY PRIMARY RESPONSIBILITY IS TO THE DEPARTMENT OF CORRECTIONS.
I HAVE READ AND UNDERSTAND THE PROCEDURES AND RESTRICTIONS IN AR 355. I UNDERSTAND MY APPROVAL FOR SECONDARY EMPLOYMENT MAY BE REVOKED AT ANYTIME.
______________________________________________________ ___________________
Employee’s Signature Date
RECOMMEND:
( ) Approved
( ) Denied _________________________________________ ___________________
Signature of Warden / Division Head Date
( ) Approved
( ) Denied _________________________________________ ___________________
Signature of Director/Designee Date
Cc:
Personnel File- Carson City