<table style="width:100%;">
<colgroup>
<col style="width: 18%" />
<col style="width: 10%" />
<col style="width: 3%" />
<col style="width: 7%" />
<col style="width: 1%" />
<col style="width: 1%" />
<col style="width: 4%" />
<col style="width: 5%" />
<col style="width: 6%" />
<col style="width: 0%" />
<col style="width: 0%" />
<col style="width: 3%" />
<col style="width: 2%" />
<col style="width: 3%" />
<col style="width: 6%" />
<col style="width: 5%" />
<col style="width: 4%" />
<col style="width: 2%" />
<col style="width: 2%" />
<col style="width: 0%" />
<col style="width: 7%" />
</colgroup>
<tbody>
<tr class="odd">
<td colspan="21">EMPLOYEE INFORMATION</td>
</tr>
<tr class="even">
<td><strong>Employee Name</strong></td>
<td colspan="20"></td>
</tr>
<tr class="odd">
<td><strong>Employee ID No.</strong></td>
<td colspan="6"></td>
<td colspan="2"><strong>Div/Dept</strong></td>
<td colspan="12"></td>
</tr>
<tr class="even">
<td colspan="21">OUTSIDE EMPLOYMENT INFORMATION</td>
</tr>
<tr class="odd">
<td colspan="2"><strong>Name of Outside Employer</strong></td>
<td colspan="19"></td>
</tr>
<tr class="even">
<td colspan="6"><strong>Nature of Outside Employer’s
Business</strong></td>
<td colspan="15"></td>
</tr>
<tr class="odd">
<td colspan="21"></td>
</tr>
<tr class="even">
<td colspan="12"><strong>Nature of work you will be expected to perform
(be specific)</strong></td>
<td colspan="9"></td>
</tr>
<tr class="odd">
<td colspan="21"></td>
</tr>
<tr class="even">
<td colspan="4"><strong>Estimated hours/month of outside
work:</strong></td>
<td colspan="7"></td>
<td colspan="10"></td>
</tr>
<tr class="odd">
<td colspan="3"><strong>Estimated dates of employment:</strong></td>
<td><strong>From</strong></td>
<td colspan="6"></td>
<td colspan="3"><strong>To</strong></td>
<td colspan="6"></td>
<td colspan="2"></td>
</tr>
<tr class="even">
<td colspan="14"><strong>Do you have or will you have a written
agreement with the outside employer?</strong></td>
<td><strong>Yes</strong></td>
<td></td>
<td><strong>No</strong></td>
<td colspan="2"></td>
<td colspan="2"></td>
</tr>
<tr class="odd">
<td colspan="21"><blockquote>
<p>Note that any written agreement must be reviewed and approved by the
LBNL Technology Transfer and Intellectual Property (TTIP) Department
prior to execution. Such agreements must include approved language
protecting the Laboratory’s intellectual property. Please provide a copy
of the proposed agreement along with this request.</p>
</blockquote></td>
</tr>
<tr class="even">
<td colspan="14"><strong>To the best of your knowledge, is any other
LBNL employee with whom you have a reporting relationship providing or
planning to provide services to the above named
organization?</strong></td>
<td><strong>Yes</strong></td>
<td></td>
<td><strong>No</strong></td>
<td colspan="3"></td>
<td></td>
</tr>
<tr class="odd">
<td colspan="21"><blockquote>
<p><strong>If yes, identify each such employee and describe
his/her/their duties with the outside organization.</strong></p>
</blockquote></td>
</tr>
<tr class="even">
<td colspan="21"></td>
</tr>
<tr class="odd">
<td colspan="21">EMPLOYEE CERTIFICATION</td>
</tr>
<tr class="even">
<td colspan="21"><p>I certify that the information provided above is
true and complete to the best of my knowledge I have read and understood
the policy references pertinent to my situation.</p>
<blockquote>
<p><strong>•</strong> If a possible conflict of interest arises in the
course of the business activity, I will promptly notify my Division
Director and abide by LBNL direction concerning such conflict.</p>
</blockquote></td>
</tr>
<tr class="odd">
<td colspan="21"><blockquote>
<p><strong>•</strong> I agree to promptly advise my Division Director
whenever any change or termination occurs in my business relation with
the above named Outside Business Organization, and promptly respond to
all LBNL requests for information regarding such changes.</p>
<p>• I understand that I am not to conduct my outside business activity
during my Laboratory work hours and may not use any Laboratory
facilities or equipment in the conduct of such activity.</p>
</blockquote></td>
</tr>
<tr class="even">
<td colspan="8"></td>
<td colspan="13"></td>
</tr>
<tr class="odd">
<td colspan="8"><strong>Employee Signature</strong></td>
<td colspan="13"><strong>Date</strong></td>
</tr>
<tr class="even">
<td colspan="21">APPROVAL</td>
</tr>
<tr class="odd">
<td colspan="21"><p>Upon discussion with the above named LBNL employee
regarding the services to be provided to the above named organization,
and upon review of the information provided on this form, I approve of
the outside employment described above. I have considered:</p>
<blockquote>
<p>• Avoidance of unfair competitive advantage</p>
<p>• Separation of LBNL and private interests</p>
<p>• Protection of information not yet in the public domain</p>
<p>• Non-competition with LBNL projects</p>
<p>• Prohibition against the use of LBNL facilities, equipment, or work
time for any purpose other than official Laboratory business</p>
</blockquote></td>
</tr>
<tr class="even">
<td colspan="5"></td>
<td colspan="3"></td>
<td colspan="10"></td>
<td colspan="3"></td>
</tr>
<tr class="odd">
<td colspan="5"><strong>Supervisor Signature</strong></td>
<td colspan="3"><strong>Date</strong></td>
<td colspan="10"><strong>Group Leader/Dept. Head Signature</strong></td>
<td colspan="3"><strong>Date</strong></td>
</tr>
<tr class="even">
<td colspan="5"></td>
<td colspan="3"></td>
<td colspan="10"></td>
<td colspan="3"></td>
</tr>
<tr class="odd">
<td colspan="5"><strong>Division Director Signature</strong></td>
<td colspan="3"><strong>Date</strong></td>
<td colspan="10"></td>
<td colspan="3"></td>
</tr>
<tr class="even">
<td colspan="5"></td>
<td colspan="3"></td>
<td colspan="13"></td>
</tr>
<tr class="odd">
<td colspan="5"><strong>Print Division Director Name</strong></td>
<td colspan="3"></td>
<td colspan="13"></td>
</tr>
<tr class="even">
<td colspan="21">APPROVAL TIME LIMIT</td>
</tr>
<tr class="odd">
<td colspan="21">This approval expires on the termination date of the
association or one year from the date of approval, whichever comes
first. Continuation of an outside business activity beyond two years
requires submission of a new request.</td>
</tr>
</tbody>
</table>

**Distribution:** Conflict of Interest Coordinator

**Instructions**

Use this form to request approval for outside employment activity,
including consulting. Information provided in this form is used in
conflict of interest reviews, to update the LBNL employee-vendor
database, and for reporting to the Department of Energy. A separate form
is to be used for each outside activity.

**Policy References**

RPM Conflict of Interest (See RPM Chapter 10)

-   Allows LBNL employees to engage in outside employment, consulting,
    or other business activities if there is no conflict with and does
    not detract from their work at the Laboratory.

-   Prohibits the use of privileged or official information for personal
    financial gain.

-   Prohibits the use of LBNL facilities, tools, supplies, materials,
    and equipment for any purpose other than official LBNL business.

**California State Law on Conflict of Interest**

University policy and the State of California Political Reform Act of
1974 may require disqualification from participation in certain
decisions when a financial conflict exists.

**Privacy Notification**

The State of California Information Practices Act of 1977 (effective
July 1, 1978) requires the University to provide the following
information to individuals who are asked to supply information about
themselves:

-   The principal purpose for requesting the information on the form is
    to enable consideration of your request to engage in outside
    business activity in accordance with Laboratory, University, and DOE
    regulations.

-   Furnishing all information requested on this form is mandatory.
    Failure to provide such information will delay or may even deny your
    request for outside business activity. Information furnished on this
    form may be used by various Laboratory and University departments
    for personnel administration and may be transmitted to the Federal
    and State governments as required by law.

-   Individuals have the right to review their own records in accordance
    with Laboratory and University policies. Information on these
    policies can be obtained from the Human Resources Department.

-   Responsibility for maintaining the information contained on this
    form resides with the Human Resources Department.

**Questions**

General questions about the policies related to outside employment
should be addressed to your Division Director. Questions concerning
patents should be addressed to the Technology Transfer and Intellectual
Property Management Department and those concerning conflict of interest
to the Laboratory Conflict of Interest Coordinator, coi@lbl.gov.