Mitchell, Christopher~' ! 1 C.'
CITY OF MIAMI BEACH 2008 NOV' c6 A~ ! ~ ~ 23
REQUEST FOR APPROVAL OF OUTSIDE EMPLOYMENT
Page 1 of t ~.iT ~' ~~LI~r~3`e'S ~~~- i
I. TO BE COMPLETED BY EMPLOYEE -This Form must be completed & approved prior to
beginning any other employment
A. INFORMATION REGARDING CITY OF MIAM/ BEACH CMB EMPLOYMENT
ID # DEPARTMENT /DIVISION
EMPLOYEE NAME: LAST NAME, FIRST NAME, MIDDLE NAME
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WORK PHONE # HOME PHONE #
JOB TITLE
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SOR RK PHONE #
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TO BE COMPLETED BY SUPERVISOR: DO OU AGREE WITH THE
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AL WORK DAYS AND TIMES INFORMATION IN THIS SECTION? ~ YES NO
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B. INFORMATION REGARDING OUTSIDE EMPLOYMENT
EMPLOYEE ID # DEPARTMENT /DIVISION
NAME OF BUSINESS OR INDIVIDUAL HIRING CMB EMPLOYEE
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JOB TITLE 1/)IOE~ PHONE #
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' TYPE OF BUSIN S
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WORK PHO E #
SUPERVISOR
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DATE OF HIRE
NORMAL WORK DAYS AND TIMES ,~ (` l~
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WHAT DUTIES MIGHT BE CONSIDERED TO BE A CONFLICT OF INTEREST
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This form has 2 pages - be sure to complete both pages
CITY OF MIAMI BEACH
REQUEST FOR APPROVAL OF OUTSIDE EMPLOYMENT -CONTINUED
PAGE 2 of 2
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By signing below,. I certify that all of the information given on page one (1) of this document is true, accurate, and
complete to the best of my knowledge. I understand that all information is subject to investigation and that falsification,
omission, or misrepresentation is sufficient cause for disciplinary action, up to and including termination. I also understand
that I am responsible for informing my supervisor in writing if any information about my outside employment changes,
especially if there arises any possible conflict of interest. Failure to do so may lead to disciplinary action, including termination
of employment with the City of Miami Beach. This request for approval will be made on a yearly basis.
EMP 'SIGNATURE ~ DATE ITNESS G T,I1RE
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E PLOYEE NAME ID NUMBER
II.
TO BE COMPLETED BY EMPLOYEE'S CITY OF MIAMI BEACH DEPARTMENT
PLEASE CIRCLE ON APPROVED SUPERVISOR SIGNATURE ~ DATE
NAME OF SUPERVISOR C ~-~""C ~ DISAPPROVED
PLEASE CIRCLE APPROVEb DIVI 10 H D SIGNATURE & DATE
NAME OF DIVISION HEAD DISAPPROVED
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PLEASE CIRCLE ONE PPROVED DEPARTMENT IGNATURE & DATE
NAME OF DEPARTMENT DIRECTOR DISAPPROVED
PLEASE CIRCLE ONE APPROVED CIT MANAGER SIGNATURE & DATE
CITY MANAGER DISAPPROVED
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this form has 2 pages - be sure to c¢r1nplet~bbth pages ~-J
M:\$CMB\HUMARESO\Outside Employment Fonn 10 06 03.doc REV: io/os/o3
By signing below, t certify that I have read this form completely and that I do not have any other employment. I understand
that before I start any other employment, I must request and obtain the above approvals. I further understand that failure to
comply with Outside Employment procedures could lead to disciplinary action up to and including termination of my
employment with the City Of Miami Beach.