Form A

FACULTY AND RESEARCH PERSONNEL CONSULTING ACTIVITY REQUEST FOR APPROVAL OF EXCEPTION TO POLICY

Name _______________________________________________________________

University Title_________________________________________________________

Calendar Year________________ Unit__________________

1. Describe consulting activity proposed

2. Name agency for which consulting will be undertaken *

*(If the consulting activity is of a professional character and is covered by a body of professional regulations, which makes the  consulting relationship confidential, cite the nature of the work and the applicable professional regulations.)

3. Scope of consulting activity for exception is sought

List Dates                                                      List Hours on Each Date

4. Please indicate below which statutory exception applies to this consulting activity

_____ Consulting of which the University is primary beneficiary

_____ Consulting which is professional service involving only a nominal stipend.

_______________________________                             ______________________________

Signature of Applicant                                            Date Signature of Chair    Date

Exception from time limitations approved______  disapproved_______

________________________________________________________________________

Signature and Title of Dean or Director  Date

c:  Applicant

Applicant?s personnel file