Antwan Terry 2021DocuSign Envelope ID: A5818749-E278-4008-82BE-CC4 B7ABDC8BF
MII\MIOADE. OUTSIDE EMPLOYMENT STATEMENT
For Full tune County and Mam:cpai é/ployees
+ ul- imne County including Pubic Health Trust) and mucal emtoyees engagng n outside errloyner: rust'de at 3rua so """
by July 1st of each yea mn accordance wth Section 2 1' 'k)!2) 0t the Marv Dade County Code
Disclosure tor Tax Year Ending Last tame
z021 l4
Maling Address Street Number, Street Name, or P0. B0¥
[e o «¢
City. State, p
First Name Middle tame/nut.al
il vo neme address s exem: 'romn ublc records pursuant to Fonda Statutes $119.07. pease see note on the tollowrg page and check here.]
Filing as an Employee (check one)
[J County O Public Health Trust O Municipal
Department
Dad shoo
(Municipality)
p rvision
Po5.tan or Tite mntoyee ID Num ber Work telephone
9ase us: ¡re sorces t outs.de employment (nclucng selt-employment). the nature ot the work, and the total amnomnts a! money or
ccmpensa!on you recerved tor each source ot outsce empioyment it no income or compensaton was received tcm a pa'.'@
erlo,men7t, enter zero 40 tor that organzatan n :re section elow It continued on a separate sheet, check here. []
Name and Address
of the Source o! Outside Income
Nature of the
Wark Performed
Iotal Amount of Money or
Compensation Received
I rerepy swear (or at'rm that the irtormna!on above s a '! ad Correct st 'er en
/'
Signature 0t Person 0sclosi ng
I
2, 3
D0ale signed
RECHE) BY ELEC{GAS OF PARIME!
Hardcopy
¡ECEIVE
JUL 18 2022
CITY OF MIAMI BEACH
OFFICF OE TE CIT CLERK
OFFICE USE ONLY Acted Y ' ' 0etrny ) I
DocuSign Envelope ID: A5818749-E278-4008-828E-CCAB7ADC8BF
1
CITY OF MIAMI BEACH
REQUEST FOR APPROVAL OF OUTSIDE EMPLOYMENT
TO BE COMPLETED BY EMPLOYEE City of Mam Beach employees ray accep: outse er: yen as orq as
ne employment s not contrary, detrimental or adverse to the interests ot the Cw'y and as /Gng 05 'y e'
equipment or matenal rs used
Imus torn must be completed and approved pnor to beginning any outside em ployment ñcquests for a0·d
outside employment must be made on a yearly basts (even if for the same outside orioyment that nad teen
provously approved)
Cy employees engaging in outside employment must also file an Outside Employment Statement' form wt the
Otfce of the City C'erk by July 1" of each year, in accordance with Section 2-11 1(k«)(2) 0' the Mam-Dade Co. ''y
Code
INFORMATION REGARDING CITY OF MIAMI BEACH EMPLOYEE
¡, 5,,5 s, NF S NAME Mi0é NM - p ecvñ ii8a
INFORMATION REGARDING OUTSIDE EMPLOYMENT
LV•~•~:· ",·JS:',. -S ·ï-.,,,•ii,.lA. ON O'< 1'-0 \,-OU.\c I 1R •;e, \'', i•.'PU)VË < _
f r. Dl. 'Ar!'v ha-l> D5 I .•
I
·:: ;,_:>~ C',. '\JV8::~
? I' 1 r ) £7ii4M!:?OY nit+O.
·°'
+ VES NO
Thus farm has ? pages be sure to comp ete both pages
Employee signature required on page
DocuSign Envelope ID : A5818749-E27B-4 008-82BE-CC4B7ABDC8BF
'
I
CITY OE MAM PE A H
RE QUES T FO R AP PRO VAL OF OUTSIDE EM PI O YM E NI CONTINUE D
PAGE 2 o' 2
y sqmmg beow ' cert ty tnat all of the information gven on page one t1) of tmis d ocument tte .0 a t
cm /ete to the pest o' my knowledge I understand that all information rs sub,ect to invest.g ator an d mg: fj' ¡! O
muss0n or mvsrepresentation is sufficient cause for disciplinary acton up to and includin g torr at yr a
understand that l am responsible for informing my supervi sor in w ntn g f any information about my at !e empower
arçes espec ally ! there anses any possible con'lt of interest Falure to do so may lead to drsc:platy at
'i udt g ermnatuon af emi oym ent wath the Coty of M a m Beach This re quest for aproval Of outs de emp/0yme' w
be made on a yearly asis
' ' ()N
t. \ '·
)
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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
7/14/2022 19:4 2 AM ED T
7/14/2022 1 10:57 AM ED T
M arla Alpizar xrp #e ISA9P ROV O
PLEASE CIRCE ON-
Areo ~--------------~--
M ark Taxis DISAPPROVE
7/14/2022 [ 12.18 PM EDT
7/14/2022 I 12:26 PM EDT
E9 A C0 5 18F 2AA4 1A
l! you have any questions regardi ng outside employment, please con!act th e Hu n a Res0/res5 )er 31
305 673 7524