Annual Report of Outside Employment for Faculty and Administrative Staff	EPERS-123 1/15/2015
Location
Fiscal Year	I have had outside employment during this fiscal year	Yes	No
An Outside Employment Request for this employment was submitted and approved	Yes	No
Name	Employee ID	Title	Department	Period of Outside Employment	Estimated hours/ month	Actual hours worked per year	Approval Date	Nature of Outside Employment and Relationship to University Assignment
(Sample) John Expert	Associate Professor	Cooperative Extension Service	1/00 – 6/00	5 hours monthly	12/99	Consulting outside the state
I understand that it is my responsibility to notify the Human Resources Director if I become an owner of, or become involved in, a business other than the University of Arkansas Cooperative Extension Service during the coming year.
Employee Signature	Date
Employee Name (printed)