Disclose Secondary Employment and / or Private Business Form

* Required Field

Your Contact Information

* First Name

* Last Name

* Employee Number

Address

City

State

Zip Code

* Phone

* Email

* County Job Title

* Supervisor's Name

* County Department

Other Department

* Supervisor's phone number

* Days and Hours Worked at County position (i.e. Mon and Tues 8:30 am - 4:30 pm)

* Brief Description of County Job Duties and Responsibilities

* Name of Secondary Employer/Private Business Activity

* Address of Secondary Employer/Private Business Activity

* City

* State

* Zip Code

* Secondary/Business Activity Job Title

* Supervisor's Name

* Supervisor's Phone Number

* Date Secondary Employment/Private Business Activity Began or will begin

* Days and Hours Worked (i.e. Mon and Tues 6:00 pm -9:00 pm)

* Briefly describe your job duties and responsibilities

Supporting Documentation

I certify that the information contained in this form is true, complete and accurate to the best of my knowledge.

* Electronic Signature

* Date

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