Secondary Police Employment Request
Employee Name:
Secondary Employer’s Name and Business:
Secondary Employer’s Address: Secondary
Employer’s Phone Number: Date of
Request:
Description of Work:
Average # of Hours Worked Per Week:
When is Work Performed:
Uniform:
Yes
No
Employee Signature: Date: The undersigned acknowledges that they have read and understand the Village of Pinehurst “Secondary Police Employment Policy” pertaining to secondary police employment and agree to comply with the order or any other requirements of the Village of Pinehurst regarding secondary employment. You are advised to inquire with the secondary employer regarding liability for Workers’ Compensation and general liability insurance coverage of you as an employee.
Accept Deny Accept Deny Accept Deny Accept Deny
Supervisor Signature:
Date:
Department Head:
Date:
HR Signature:
Date:
Village Manager Signature:
Date:
Human Resources Department 395 Magnolia Rd. - Pinehurst, North Carolina 28374 (910) 295-1900 - Fax (910) 295-4434 - www.vopnc.org Page 1 of 1
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