ࡱ> .0-7 bjbjUU &7|7| l*******>   8B N>X2nnnnnIII$ ]*IIIIIy**nnyyyI *n*nyIy4y:,**nb `gmNj> S 3 (0X=RV]Vy>>**** app Request for Permission to Engage in Consulting Activities Name: _____________________________________________Rank_______________ Department or Unit: ________________________________________________________________ College or School: ________________________________________________________________ Proposed Employer: ________________________________________________________________ Period of Agreement: Beginning Date:___________Ending Date:___________ (Maximum duration for approval is one year.) Approximate Time Involved per Month: ________________________________ Normal maximum of 36 hours per month. Nature of Work/Problem (if class, indicate class title and schedule): _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ Please answer the following questions. Attach details to explain each  yes response. 1. Will this consulting activity alter or interfere with meeting your obligations to students, faculty, colleagues or UAH? % Yes (Attach details) % No. 2. Will you involve students or university facilities in any capacity in work performed under the proposed agreement? % Yes (Attach details) % No. 3. Do you or any members of your immediate family participate as an officer, partner, director, trustee, employee, advisory/other board member, or agent in any capacity with the proposed employer or a subcontractor or vendor or of any organization providing goods and/or services for the proposed project? % Yes (Attach details) % No. 4. Do you or any member of your immediate family hold more than five percent (5%) actual or beneficial ownership of the voting stock or controlling interest of the proposed employer or a subcontractor or vendor or any organization providing goods and/or services for this proposed project? % Yes (Attach details) % No. CERTIFICATION: This request is made pursuant to the Consulting and Conflict of Interest Policies detailed in the Faculty Handbook. I certify that I have read and understand the policies and will abide by them. I understand that it is my responsibility to insure that my services avoid any conflict of interest and that the permission granted is subject to termination for reasonable cause. __________________________________ _______________________ Signature of Applicant Date ( Approved _________________________________ ______________________ ( Disapproved Chair Date ( Approved _________________________________ ______________________ ( Disapproved Dean Date Distribution: Provost and Vice President for Academic Affairs; Dean; Chair; Applicant efg*rx z T V "<B&?@_` joCJ6CJ55CJOJQJ^JCJCJCJCJ5CJ5\+,fgYZ*+r;| $$dNa$dh &dP $&dPa$$a$|~ "?^_$a$ &dP &dP $&d P a$$a$$&P1h/ =!"#$@% i4@4 NormalCJ_HmH sH tH <@< Heading 1$$@&a$ 5CJ\2@2 Heading 2$@&5\:@: Heading 3$$@&a$>*CJ<@< Heading 4$$@&a$ 5>*\8@8 Heading 5$$@&a$5\<A@< Default Paragraph Font0B0 Body Text 6CJ].P@. Body Text 2CJ,, Header  !, ", Footer  !HC@2H Body Text Indent$^a$6]0Q@B0 Body Text 3$a$.>R. Title$a$ 5CJ\ ,fgYZ*+r;>?st ? ^ _    00I0I0I0I0I0I0I0I0I0I0I0I0I0I0I0I0I0I0I0I0I0I0I0I0I0I0I0I0I0I0I0I0I0I0I0I0I0I0I0I0I0I0 |  8@0(  B S  ?     Research AdministrationMC:\WINDOWS\Application Data\Microsoft\Word\AutoRecovery save of Document2.asdResearch Administration>E:\gloria\WORD\ADMIN\WORKING\TRAINING\Consultant Agreement.docGlorianC:\Documents and Settings\gloria\Application Data\Microsoft\Word\AutoRecovery save of Consultant Agreement.asdGloria>E:\gloria\WORD\ADMIN\WORKING\TRAINING\Consultant Agreement.docGloria>E:\gloria\WORD\ADMIN\WORKING\TRAINING\Consultant Agreement.docGloria>E:\gloria\WORD\ADMIN\WORKING\TRAINING\Consultant Agreement.docGloria>E:\gloria\WORD\ADMIN\WORKING\TRAINING\Consultant Agreement.docGloria>E:\gloria\WORD\ADMIN\WORKING\TRAINING\Consultant Agreement.docGloria>E:\gloria\WORD\ADMIN\WORKING\TRAINING\Consultant Agreement.docUAH;E:\gloria\WORD\ADMIN\WORKING\TRAINING\RequestForConsult.docf?x-%9N88^8`o(.^`o(. L ^ `L.  ^ `.xx^x`.HLH^H`L.^`.^`.L^`L.^`o(.^`o(.pLp^p`L.@ @ ^@ `.^`.L^`L.^`.^`.PLP^P`L.-%9Nf?&s        ʃx       @  t$  X  @ $@UnknownGz Times New Roman5Symbol3& z Arial?5 z Courier New;Wingdings"hjfjfRi&( !r0d> 2Q'THE UNIVERSITY OF ALABAMA IN HUNTSVILLEResearch AdministrationUAHOh+'0( 4@ \ h t (THE UNIVERSITY OF ALABAMA IN HUNTSVILLEHE Research Administrationeseese Normal.dotmUAH2HMicrosoft Word 9.0t@F#@p܋]@ INj@ INj( ՜.+,0 hp|  UAH>  (THE UNIVERSITY OF ALABAMA IN HUNTSVILLE Title  !"#$&'()*+,/Root Entry FPmNj11TableVWordDocument&SummaryInformation(DocumentSummaryInformation8%CompObjjObjectPoolPmNjPmNj  FMicrosoft Word Document MSWordDocWord.Document.89q