The Undersigned, Acting As the Authorized Agent Or Representative For

Police Department SECONDARY EMPLOYMENT WORK REQUEST The undersigned requests the Edenton Police Department to authorize officers to work in an off-duty capacity. I/we further represent that:

1. Type of location to be worked: City Rental Facility Restaurant Residence Club House Open Field Other (specify)

2. Employment Date(s)/Time(s) mm dd yy mm dd yy From / / to / / Hours am / pm to am / pm

3. Event/Job Contact: Name: Title:

mm dd yy Date of birth / / Driver’s License #: State

Address City State Zip

(area code) Ext. (area code) Ext. Hm Ph: ( ) - Wk Ph: ( ) - Cell Ph: ( ) -

4. Nature of event: Wedding Birthday Anniversary Graduation Private Party Other (specify)

5. The duties assigned may include Crowd Control Traffic Control Indoor / Outdoor Patrol Other (specify)

6. Number of guests expected: 0-100 101-200 201/more Advertised by: Radio TV Paper Flyer Numbered Invitation Open Invitation Other (specify)

7. The address/location to be worked is:

(area code) Ext. Edenton, North Carolina. The job site telephone number is ( ) -

8. NOTE: Officers cannot work at an event where there is the sale and/or consumption of alcohol beverages, except by the explicit permission of the Chief of Police. Alcoholic beverages be allowed? Yes No Cash bar? Yes No Open bar? Yes No Liquor type and quantity Beer / Wine / Hard Liquor /

9. The above named person(s) acknowledges that the Town Of Edenton and/or the Edenton Police Department are not responsible for the acts or omissions of off-duty officers working in a secondary employment capacity. This event will will not carry liability insurance for the officer.

10. All payments for off-duty employment must be made directly to the officer. Any business requiring invoicing for payment must make arrangements through the Secondary Employment Detail.

Officer(s) Rate of pay will be $ per hour (minimum $25.00 per hour)

AGENT / REPRESENTATIVE SIGNATURE DATE

OFFICER ASSIGNED DATE

UNIFORM OPERATIONS CAPTAIN DATE

Edenton Police Department, 305 W. Freemason Street, Edenton NC 27932, Telephone 252-482-5144 Fax 252-482-4999