Evan S. Prentiss Request Approval for Outside Employment 2016 A, i ,.
CITY OF MIAMI BEACH
REQUEST FOR APPROVAL OF OUTSIDE EMPLOYMENT
TO BE COMPLETED BY EMPLOYEE—City of Miami Beach employees may accept outside employment as long as
the employment is not contrary, detrimental or adverse to the interests of the City, and as long as no City time,
equipment or material is used.
This form must be completed and approved prior to beginning any outside employment. Requests for approval of
outside employment must be made on a yearly basis (even if for the same outside employment that had been
previously approved).
City employees engaging In outside employment must also file an "Outside Employment Statement" form with the
Office of the City Clerk by July 1" of each year, in accordance with Section 2-11.1(k)(2) of the Miami-Dade County
Code.
INFORMATION REGARDING CITY OF MIAMI BEACH EMPLOYEE
EMPLOYEES NAME:LAST NAME,FIRST NAME,MIDDLE NAME: EMPLOYEE ID NUMBER: —
Prentiss, Evan Scott 18363
JOB TITLE: HOME TELEPHONE NUMBER:
Lieutenant 305-283-5892
•
DEPARTMENT/DIVISION: WORK TELEPHONTE NUMBER:
Fire Rescue 305-673-7136
SUPERVISORS NAME: CELLULAR TELEPHONE NUMBER d
Doug Thompson 305-283-5892
NORMAL WORK DAYS AND TIMES:
Fire Department "B" shift
INFORMATION REGARDING OUTSIDE EMPLOYMENT
NAME OF BUSINESS,ORGANIZATION OR INDIVIDUAL HIRING OMB EMPLOYEE:
Baptist Health of South Florida
ADDRESS OF OUTSIDE EMPLOYER:
8900 N Kendall Drive
TELEPHONE NUMBER:
786-596-1960
JOB TITLE THAT OMB EMPLOYEE WILL HOLD:
Clinical Learning
NAME OF OUTSIDE EMPLOYMENT SUPERVISOR:
John Mouw
NORMAL WORK DAYS AND TIMES:
Dates vary, 8 am -5 pm
DESCRIPTION OF DUTIES:
Education of American Heart Association classes to employees of Baptist Health
WHAT DUTIES MIGHT BE A CONFLICT OF INTEREST WITH YOUR CMB POSITION?
None
WILL YOUR PROPOSED OUTSIDE EMPLOYER RELEASE YOU IF AND WHEN YOU ARE CALLED FOR EMERGENCY SERVICE BY THE CITY?
GI YES D NO
This form has 2 pages—be sure to complete both pages.
Employee signature required on page 2.
CITY OF MIAMI BEACH
REQUEST FOR APPROVAL OF OUTSIDE EMPLOYMENT-CONTINUED
PAGE 2 of 2
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 of outside employment will
be made on a yearly basis.
EMPLOYEE NAME: EMPLOYEE ID NUMBEa:
Evan ra' 's 18363
EMP , j: D E: f
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TO BE COMPLETED BY EMPLOYEE'S SUPERVISOR, DIVISION DIRECTOR, DEPARTMENT DIRECTOR,
ASSISTANT CITY MANAGER AND CITY MANAGER
NAME OF SUPERVISOR PLEASE CIRCLE ONE: SUPE- OR SIGNATU &DATE
(4. �;s.�t.�li APPROVED DISAPPROVED /,/,' S 3
NAME OF VISION DIRECTOR - E ONE: DIVISION%r CTO'SIGMA URE&D E
APPROVED DISAPPROVED
E D PA ENTDIREECTOR PLEASE CIRCLE ONE: 0 •A• T I DIR C OR SIGNATURE&DATE
1/1 1 • DISAPPROVED ; 6z•1%,
SISTANT CITY MANAGER - i• E CIR L ONE: •ti$.ISTANT CI MANAGER SIGNATURE&DATE
APPROVED DISAPPROVED
CCIITYY�MANAGER PLEASE CIRCLE ONE: C MANAG'•'SIGNATURE&DAT
V�mr ti mOra le s (APP OV DISAPPROVED & 11.
If you have any questions regarding outside employment, please conta t the Human Resources Department at
305.673.7524.
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