HR 1.20 (7/91)

1.   Employee: ________________________________________________________

2.   UNCW Department: ________________________________________________

3.   Position Presently Held at UNCW: _____________________________________

4.   Name and Type of Business
      of Secondary Employer: _______________________________________________

      __________________________________________________________________

5. Working Hours for Secondary Employment:

Days: ______________________________________________________

Hours: _____________________________________________________

I understand and accept that approval of any type of secondary employment is contingent upon
there being no conflict of interest with my primary employer (the University of North Carolina at
Wilmington) and that at no time, under any conditions, will I allow any secondary employment to
interfere with my duties as an employee of the University of North Carolina at Wilmington. If any
conflict occurs, I understand and accept that approval is automatically revoked.

                  ______________________________   ____/____/____
6.                         Signature of Employee                          Date

7.     [   ] Approval Granted

        [   ] Approval Denied

If approval is denied, give reason: ___________________________________________

_____________________________________________________________________

                 ______________________________   ____/____/____
8.                       Signature of Immediate Supervisor               Date

                 ______________________________   ____/____/____
9.                       Signature of Dept Head, Director, or Dean       Date      

Distribution after approvals:    Forward original to Human Resources.
                                                        Return copy through appropriate supervisory channels to employee.