DocuSign Envelope ID: 8AE3A8F5-0188-414F-838A-AE233AFCA785

TELECOMMUTING OR REMOTE WORKING REQUEST

Employee Name: ____________________________________

Phan Tan Vuong

Type of Agreement (Employee to check appropriate box):

x Telecommuting (maximum two days per week)

Remote Working (five days per week)

January 30, 2023

Start Date of Agreement (beginning of a pay period): _____________
January 31, 2024
End Date of Agreement (if applicable): _________________

Proposed Work Location if Remote

365/36/21 Xo Viet Nghe Tinh, Ward 26, Binh Thanh District

Street Address: _______________________________________________________________

Ho Chi Minh, 70000

City, State, Zip: _______________________________________________________________

Proposed Telecommuting - (Employee to check all boxes that apply)

Monday x Tuesday Wednesday Thursday x Friday

I have read the FHI 360 Telecommuting and Remote Working Policy (POL 03036) and understand and agree
to the conditions therein. I understand and agree that the telecommuting or remote working arrangement
may be terminated or modified at any time at the discretion of FHI 360, and that this agreement is not a
contract of employment. Furthermore, I understand that it is my responsibility to obtain any necessary
work authorization required by the host government and to pay all applicable local taxes in addition to
those incurred as a US-based employee. FHI 360 strongly recommends that I consult a tax advisor as early
as possible to determine tax liabilities in both the U.S. and the host country. I confirm that I have the
necessary equipment, whether personal or FHI 360-issued, and am responsible for independently
arranging appropriate workspace in which to perform my job responsibilities in a telecommuting or remote
working capacity.

Employee Signature: _____________________________________ Date: ________________________

February 2nd, 2023

Immediate Supervisor Only – Check appropriate box

Approved
Denied and Reason: _____________________________________________________________
**Supervisor: If denied, please provide reason for denial, sign and submit form. Follow up directly with
employee to discuss denial.

Supervisor Signature: _____________________________________ Date: ________________________

Submit Request via the Online Service Portal: Human Resources Employee Service Center

APX 03036_01 Effective Date: 26 JUN 2020 Version 4

DocuSign Envelope ID: 8AE3A8F5-0188-414F-838A-AE233AFCA785

APX 03036_01 Effective Date: 26 JUN 2020 Version 4