APPLICATION TO UNDERTAKE
PROFESSIONAL AND CONSULTATIVE WORK

Part A

Name of Staff Member __________________________________________________

Department or Section __________________________________________________
Note:  A separate application form should be completed for each professional and consultative activity undertaken.

 1.	Nature of proposed professional and consultative work.  A brief description only is requested; however, further information can be attached.  
	Refer to Professional and Consultative Work Policy, Sections 1.1.1 and 6.2.

________________________________________________________________

________________________________________________________________

________________________________________________________________

________________________________________________________________

2.	Outline the period over which the above activity is expected to extend:
(eg one day, one week, one month, 12 months, on an ongoing basis commencing from Date/Month/Year)

________________________________________________________________

________________________________________________________________

3.	Estimated time (expressed in hours per week) required to undertake the above activity:

________________________________________________________________

________________________________________________________________

I propose to undertake this work under the auspices of the University (ie as a University or Departmental Consultancy) and understand that I will therefore be covered by the relevant University insurance policies.  Tick whichever applies.

Yes 			No 

If the response above is No, proceed to Part B
If the response above is Yes, proceed directly to Part C.

Part B

UNDERTAKING FOR PRIVATE CONSULTANCY

Note:  Please ensure that all segments within this section are fully completed.

I undertake that:
1.	Before entering into any contract, I shall give the other party notice that I am contracting in a private capacity and not for the University.
2.	I shall not use either the University’s name or any headed stationery of the University in any way from which it might be inferred that I am acting on behalf of the University.
3.	All liabilities arising out of or in the course of the performance of the professional and consultative work shall be mine and the University shall be free of all responsibility in respect of that work (signed indemnity form below).
4.	I shall reimburse the University for any charges and expenses, direct or indirect, incurred by it for the work.
5.	I shall comply with the University’s rules and conditions for professional anhd consultative work.

In consideration of the University of Western Australia allowing me to undertake and retain income from this Private Consultancy activity, I agree to procure and maintain at my own expense: 

 Please circle the appropriate letter.
a.* 	Workers’ Compensation Insurance which shall comply with the laws of the State of Western Australia

b.*	Public Liability Insurance with a sum insured of not less than $10,000,000

c.	Professional Indemnity Insurance to cover any professional liabilities arising out of the discharge of my private activities.

OR

d.	I agree to provide evidence that the client has indemnified me equivalent to the requirements above.
OR

e.	I agree to carry out the work described totally at my own risk.

I hereby indemnify and hold harmless the University of Western Australia and its officers, employees and agents against all claims, liabilities, costs, damages and expenses of every kind and nature directly or indirectly arising out of or in connection with my private professional and consultative activities.

Signed _______________________________________________________________

Witness ______________________________________________________________

Date ________________________________________________________________

Part C

APPROVAL

I hereby seek approval for the activities described in Part A

Signed _______________________________________________________________

Date ________________________________________________________________

I hereby approve the activities described in Part A

Signed (Head of Department) ____________________________________________

Date ________________________________________________________________

Part D

WAIVER

Refer Professional and Consultative Work Policy, Section 7.6

The requirement for the Undertaking and the Indemnity has been waived because the work described in Part A will be conducted under the auspices of the University as a University of Departmental Consultancy.

Signed (Head of Department ) _____________________________________________

Date ________________________________________________________________