Notice of Employee Working Outside of Tennessee

This form is used to determine the applicable federal and state income tax withholding procedures for an employee who works outside of Tennessee.

If you are the employee: Please complete the form after obtaining the appropriate approvals. See APPROVALS AND CONDITIONS below.

If you are the supervisor of the employee referenced: Please complete this form when an employee starts or stops working in another state/country.

GENERAL INFORMATION
Employee Status

Employee Status I / the following employee will be working for Vanderbilt University outside of Tennessee for a period of one week or longer. I / the following employee is no longer working out of state/country. I / they have returned to work in Tennessee. The following employee is no longer working out of state/country. They are no longer employed by Vanderbilt University.
APPROVALS AND CONDITIONS
If completed by the employee:

If completed by the employee: I attest that I have been granted written approval by my supervisor and Dean or Vice Chancellor to work outside of the State of Tennessee. (Note that VC approval will be verified by HR.) I agree to abide by VUIT’s technology and security protocols for secure remote work.
If completed by the employee's supervisor:

If completed by the employee's supervisor: The referenced employee has been granted written approval by our school's Dean or division’s Vice Chancellor to work outside of the State of Tennessee. (Note that this will be verified by HR.) I have instructed the employee that they must abide by VUIT’s technology and security protocols for secure remote work.
EMPLOYEE INFORMATION
Employee Name Employee Name First Middle Last
Employee ID#
Employee Email
Out of State/Country Start Date Out of State/Country Start Date / MM / DD YYYY
Out of State/Country End Date Out of State/Country End Date / MM / DD YYYY
Description of Work Being Performed
Out of State/Country Work Address Out of State/Country Work Address
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Out of State/Country Phone Number
Out of State/Country Fax Number
DEPARTMENT INFORMATION
Department Number / Name
Department Contact Department Contact First Last
Department Contact Phone Number Department Contact Phone Number - ### - ### ####
Department Contact Email

Notice of Employee Working Outside of Tennessee

Notice of Employee Working Outside of Tennessee

GENERAL INFORMATION

APPROVALS AND CONDITIONS

EMPLOYEE INFORMATION

DEPARTMENT INFORMATION