Mara Onare 2021DocüSign Envelope ID : FCAEB E4A-1CF 7 -4 532-9B E0-B8 59D041D03AF
MIAMI-DADE . z7II
OUTSIDE EMPLOYMENT STATEMENT
For Full-time County and Municipal Employees
Full-time County (including Public Health Trust) and municipal employees engaging in outside employment must file an annual disclosure report
by July 1st of each year, in accordance with Section 2-11.1(k)(2) of the Miami-Dade County Code.
Disclosure for Tax Year Ending Last Name Middle Name/Initial
2021 '7€
First Name
/lac
Mailing Address - Street Number, Street Name, or P.O. Box
r2er
33 2
If your home address is exempt from public records pursuant to Florida Statutes $119.07, please see note on the following page and check here. O
Filing as an Employee (check one )
O County O Public Health Trust
Department
Employee ID Number
1 7
Work telephone
673%%
Please list the sources of outside employment (including self-employment), the nature of the work, and the total amounts of money or other
compensation you received for each source of outside employment. If no income or compensation was received from a particular outside
employment, enter zero (O) for that organization in the section below. If continued on a separate sheet, check here. O
Name and Address
of the Source of Outs ide Income
Nature of the
Work Performed
Total Amount of Money or
Compensation Received
o4 s
I hereby swear (or affirm) that the information above is a true and correct statement.
s ignature ot Person Disclosing
2/0l2 oz?
Date signed
RECEIVED BY ELECTIONS DEPARTMENT:
K(Hardcopy
O Electro nic Copy
RECEIVED
JUL 18 2022
CITY OF MIAMI BEACH
Er Tr (TV]ERK
OFFICE USE ONLY Accepted: Y / N Deficiency: Processed Date/Initials: Scanned Date/Initials:
138_D01-22 COE 2016
D oc ü Si gn En v el op e ID: FCAEBE4A-1CF7-4532-9BE0-B859041D03AF
~
A /BE A CH
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
EMPLOYEE'S NAME: LAST NAME, FIRST NAME, MIDDLE NAME:
LA
EMPLOYEE ID NUMBER:
I
JOB TITLE: HOME TELEPHONE NUMBER:
oeI
WORK TELEPHONE NUMBER: a- ,23-7260-
CELLULAR TELEPHONE NUMBER:
A
INFORMATION REGARDING OUTSIDE EMPLOYMENT
NAME OF BUSINESS, ORGANIZATION OR IND'DUAL HIRING CMB EMPLOYEE.
7 7n 7Do7a er, 'nrer
ADDRESS OF OUTSIDE EMPLOYER:
13 0o Cotta
TELEPHONE NUMBER:
74- 73 /330 ur 22
JOB TITLE THAT CMB EMPLOYEE WILL HOLD:
N A SIDE EMPLOYMENT SUPERVISOR:
IMES:
ç 730%u 1 p% /
0orce
WHAT DUTIES MIGHT BE A CONFLICT OF INTEREST WITH YOUR CMB POSITION?
o n ß--
WILL YOUR PROPOSED OUTSIDE EMPLOYER RELEASE YOU IF ANO WHEN YOU ARE CALLED FOR EMERGENCY SERVICE BY THE CITY? e s N o
This fo rm has 2 pages - be sure to com plete both pages.
Em ploye e signature required on page 2.
D o c ü S ign Envelope ID: FCAEBE4A-1CF7-4532-9BE0-B859041D03AF
CITY OF MIAMI BEACH
REQUEST FOR APPROVAL OF OUTSIDE EMPLOYMENT- CONTINUED
PAGE 2 of2
B y sign in g b e lo w , I ce rt ify that all of the info rm a tio n given on pag e one (1) of this do cum e nt is true , accurate, and
co m p le te to the be st of m y kno w le dg e . I un d e rstand that all info rm a tio n is su bject to in vestig ation and tha t falsification,
om issio n , or m isre prese ntatio n is suffi cie nt cau se fo r discip lina ry actio n, up to and inclu ding term ination. I also
u nd e rstand tha t I am respo nsib le fo r in fo rm in g m y sup e rv isor in w riting if any info rm a tion about m y outside em ploym ent
cha nge s, e spe ci ally if the re arise s any po ssib le co nfli ct of inte rest. Failu re to do so m ay lead to disci p linary action,
incl ud ing term in a tio n of em p lo ym e nt w ith the C ity of M ia m i Be a ch. T his req u e st for ap p ro val of outside em ploym ent w ill
be m ad e on a yea rly ba sis.
ate
EMPLOYEE ID NUMBER.
>?
DATE:
T O B E C O M P L E T E D B Y E M P L O Y E E 'S S U P E R V IS O R , D IV IS IO N D IR E C T O R , D E P A R T M E N T D IR E C T O R
A N D A S S IS T A N T C ITY M A N A G E R
NAME OF SUPERVISOR
N. 'TDIRECTOR
Joh n R ebar
PLEASE CIRCLE ONE: so DISAPPROVED
PLEASE CIRCLE ONE:
DISAPPROVED
APpkove DISAPPROVED
HUMAN RESOURCES DIRECTOR
Marla Alpizar
ASSISTANT CITY MANAGER
Mark Taxis
, IREC R SIGNATURE & DATE
7--zz
CTOR SIGNA TURE & DATE
7/6/2022 1 4:51 PM EDT
PLEASE CIRCLE ONE:
X
APPROVED DISAPPROVED
TOR SIGNA TURE & DATE
7/6/2022 \ 4:57 PM EDT
PLEASE CIRCLE ONE:
AP PRO VE D DISAPPROVED
NAGER SIGNATURE & DATE
+.k 1go 7/8/2022 1 2:19 PM EDT
E9AC0518F2AA41A. ..
If you h a ve an y que stio ns reg a rding outsid e em p lo ym e nt, plea se conta ct the H u m an R esource s D e part m ent at
305.673. 7524.
M:ISCMB\HUMARESOIOUTSIDE EMPLOYMENT Rvised 05162018.docx