REQUEST FOR MOONLIGHTING
I, ________________________________________ request permission to seek extra
employment (moonlighting) outside of my full time position as an LSU Resident.
The time frame requested is from ____________________ to
____________________.
I am seeking employment at ___________________________________ and
understand this agreement is only for this assignment. I understand I cannot
contract with another state agency and to the best of my knowledge, this is not a
state agency. My duties will be:
And I will work approximately ___________ HOURS per month. I understand I
need to obtain my own insurance for malpractice. This privilege may be withdrawn
by the Fellowship Program Director without notice or cause at any time. I will
report any changes to the Program Director.
Sincerely,
__________________________________________
Name
__________________________________________
Signature
Discussed and approved on_______________________
Date
___________________________________________
Stephen Kishner, M.D.
LSU HSC PM & R Residency Program Director