Date:

          

 

                   

Nature of Action:  ☐ Department Chair
☐Lead Instructor
☐Coordinator
	☐ Other (Explain:)
REQUIRED
Name:	Last 4 Digits SSN#:                         LOLA / Banner #:
Is this extra service paid from a grant? ☐   Yes ☐   No
Is this extra service paid from the same department organization as the employee’s primary job? ☐   Yes ☐   No

		EXTRA SERVICE DETAILS:
Campus / Site
Division / Department
Position Title
Banner Position Number
FOAPAL Account Number
	Fund		Organization	Account		Program
Budget Page / Item Number
Proposed Salary	$ ☐ Salaried ☐ Hourly
Effective Date	From:				To:
Average Hours per Week

PRIMARY JOB STATUS:

☐ faculty (9-month)	☐ grants faculty (9-month)	☐ unclassified
☐ faculty (12-month)	☐ grants faculty (12-month)	☐ other ( requires a full explanation be attached )

 
 
Description of
Extra Service:
 
 
 
 
 
 
 
 
I understand that in the event this agreement is processed following the initial pay period deadlines(s), my full agreed upon pay will be distributed across the remaining pay periods through the agreement’s ending date. I understand that if I am a faculty member, I am being compensated for extra non-teaching duties performed as an overload. I understand that if I am an unclassified employee, I am being compensated for approved extra duties to be performed outside the hours worked for my primary full-time position.    I also understand that I am responsible for documenting time worked in order to be paid on a timely basis.
 
Extra Service Employee’s Signature : ____________________________________________________________ Date: __________________________
 

Availability of Funds

3) ______________________________________   __________

       Budget Manager   Date

 
  5)_________________________ _____________   __________
  Vice Chancellor for Business & Admin. Affairs   Date
 
Approvals:     1) ________________________________________   __________       Supervisor/Division Dean             Date  
 
 
      2) ________________________________________   __________       Appropriate Vice Chancellor or Executive Dean   Date
 
 
   
                         
      4) ________________________________________   __________   Approved:

      Assistant Vice Chancellor for Human Resources   Date                 
                                             6) _________________________________________ ___________
                       Chancellor Date  

                                    Form 3242/003 (3/2020)

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