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REQUEST FOR APPROVAL OF OUTSIDE ACTIVITY

DEPARTMENT OF HEALTH AND HUMAN SERVICESREQUEST FOR APPROVAL OF OUTSIDE ACTIVITYS tandards of Ethical Conduct Regulation HHS Supplemental Ethics Regulation (5 CFR , 5 CFR (d))Initial RequestRevised RequestRenewalDATE FILED I. EMPLOYEE INFORMATION1. EMPLOYEE'S NAME (Last, First, MI)2. AGENCY (Operating/Staff Divison)(Subcomponent)3. TITLE OF POSITION4. GRADE/STEP5. FEDERAL SALARY6. APPOINTMENT TYPEPAS/PANon-Career SESC areer SESS chedule CCommissioned CorpsGSTitle 42 Other7. FINANCIAL DISCLOSURE FILING STATUSP ublic (OGE 278)Confidential (OGE 450)None8. OFFICE ADDRESSSTREETCITYSTATEZIP9. OFFICE CONTACT INFORMATIONTELEPHONEFAXCELLEMAIL10. NAME OF IMMEDIATE SUPERVISOR11. TITLE OF SUPERVISOR12. SUPERVISOR CONTACT INFORMATIONTELEPHONEFAXCELLEMAILAGENCY USE ONLYHHS-520 (1/06) (Previous Editions Obsolete)PAGE 1 OF 16 PSC Publishing Services (301) 443-6740 EF II.

If your request for prior approval is granted, the approval is effective for a period not to exceed one year from the date of approval. If you wish to continue an activity beyond the one year approval period, you must renew your request no later than thirty days prior to the expiration of the period authorized.

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  Activity, Request, Approval, Estudio, Request for approval of outside activity

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