Evan S. Prentiss Request Approval for Outside Employment 2016 (2) •
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 151 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
EMPLOYEE'S 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 TELEPHONE NUMBER:
Fire Rescue 305-673-7136
SUPERVISOR'S NAME: CELLULAR TELEPHONE NUMBER:
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 CMB EMPLOYEE:
Miami Dade College
ADDRESS OF OUTSIDE EMPLOYER:
950 NW 20 St
TELEPHONE NUMBER:
305-237-4000
JOB TITLE THAT CMB EMPLOYEE WILL HOLD:
Emergency Medical Services
NAME OF OUTSIDE EMPLOYMENT SUPERVISOR:
Jesus Sola
NORMAL WORK DAYS AND TIMES:
Dates vary, hours vary
DESCRIPTION OF DUTIES:
Education of Emergency Medical Services •
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?
EU YES ❑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 NUMBER:
Evan S. reny ." 18363
EMPLOY I4TU DATE:
TO BE COMPLETED BY EMPLOYEE'S SUPERVISOR, DIVISION DIRECTOR, DEPARTMENT DIRECTOR,
ASSISTANT CITY MANAGER AND CITY MANAGER
NAME OF SUPERVISOR PLEASE CIRCLE ONE: SUPE-VISOR SIGN; URE&DATE
Fie:keik APPROVEDAPPROVED
%/.•%i / 53I/0or
NAME OF DMSION DIRECTOR Lf CI E: DIVISION'•'ECTOR SIGNATURE& TE
APPROVED DISAPPROVED
N.A ��EPARTMENT DIRECTOR PLEASE CIRCLE ONE: DEP:• E irRECTOR SIGNATURE E&&DATE
1/IZ'/!G4 �— DISAPPROVED / (
ASSISTANT CITY MANAGER EASE CIRCLE ONE: • .-ISTANT CITY MANAGER SIGNATURE&DATE
APPROVED DISAPPROVED
CITY' u MANAGER M PLEASE CIRCLE ONE: CI, MANAG R SIGNATURE&DATE
`mm L• ' ' o ra 1 E APP VE DISAPPROVED �!r_.�� /4
If you have any questions regarding outside employment, pleas: cont:ct the Human Resources Department at
305.673.7524.
M:1$CMBWUMARESO\OUTSIDE EMPLOYMENT Rvlsed 04182011.docx