Ervin Mills 2021DocuS ign Envelope ID : 5A4 062CA2-3893-4 1CE -81FF-0376075A3BB 1
MIAMI-DADE. ELmI
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 fo r Tax Year Ending Last Name
a021 l«(l
First Name
fi o
Middle Name/Initial
D
Mailing Address - Street Number, Street Nam e, or P.O. Box
/fs u6o )y ke t fo473
City, State, Zip
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. D
Filing as an Employee (check one)
D County D Public Health Trust
(M unicipality )
Departm ent Division 3
[ hYKs
Positi on or Title ffwr o Employee ID Number
2t/e
Work telephone
78 37-477
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. []
Name and Address Natu re of the Total Amount of Money or
of the Source of Outside Incom e Work Performed Compensation Received
Hy, c{ [A M Ln +s P ir5 "d $0
# vw @' R ve i.,R ),331 3 v u ik «ne w«y
I hereby swear (or affirm) that the information above is a true and correct statement.
Signature of Person Disclosing
Dlt e si gned
RECEIVED BY ELECTIONS DEPARTMENT:
D Hardcopy
D Electr onic Copy
RECEIVED
JUL 18 2022
CITY O F MIAMI BEACH
OFFICE OE TE CITY CLERK
OFFICE USE ONLY Accepted: Y / N Deficiency: Processed Date/Initials: Scanned Date/initials.
138_01-22 COE 2016
o c u Si gn Envelope ID: 5A062CA2-3893-41 CE-81 FF-0376075A3BB 1
4/A 4/BEACI I/ A/V i I I l
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 "O utside E m ploym ent Statem ent" 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: EMPLOYEE ID NUMBER: M[ls ,Ero,Devent«e 24o
JOB TITLE: HOME TELEPHONE NUMBER:
flui@i p«l o« /a II
DEPARTMENT/DIVISION: WORK TELEPHONE NUMBER:
a«K }, [ere-Hie 7g-37-772
SUPERVISOR'S NAMé CELLULAR TELEPHONE NUMBER:
Ja \/2 2 s o
NORMAL WORK DAYS AND TIMES:
S0la4.'i. 36a-7 e fl: Tc«qr-53e Ty:/An-5-5 w) T4-5·3pv -
INFORMATION REGARDING OUTSIDE EMPLOYMENT
NAME OF BUSINESS, ORGANIZATION OR INDIVIDUAL HIRING CMB EMPLOYEE:
(+» of ft@
ADDRESS OF OUTSIDE EMPLOYER:
Hl++ $w 1 4 fe , %a. ¡1,33136
TELEPHONE NUMBER:
305- Ht- )3 6v
JOB TITLE THAT CMB EMPLOYEE WILL HOLD:
evz «+l L ber'
NAME OF OUTSIDE EMPLOYMENT 51,JPERVISOR:
Kn rhos
NORMAL WORK DAYS AND TIMES:
[loh,. qitn»-). 7p [l,: ¡.r-):3p» }rd -:ev?
DESCRIPTION OF DUTIES: - -
[nliwy hárh&is5 k; td ,1+ cr+il, leo pa«Y-
WHAT DUTIES MIGHT BE A CONFLICT OF INTEREST WITH YOUR CMB POSITION?
tlo ¡l-5 i(l e e, cft4 oE «tos
WILL YOUR PROPOSED OUTSIDE EMPLOYER RELEASE YOU IF AND WHEN YOU ARE CALLED FOR EMERGENCY SERVICE BY THE CITY?
dves ONO
This form has 2 pages - be sure to complete both pages.
Employee signature required on page 2.
o c u Si g n En v el op e ID: 5 A 0 6 2 C A2 -3 8 9 3 -4 1 CE -8 1 F F -0 3 7 6 0 7 5 A 3 BB 1
CITY OF MIAMI BEACH
REQUEST FOR APPROVAL OF OUTSIDE EMPLOYMENT- CONTINUED
PAGE 2 of 2
B y sig n ing be low , I ce rt ify that all of the info rm ation given on page one (1) of this docum ent is true, accurate, and
co m p le te to the be st of m y know ledge. I understand that all info rm ation is subject to investigation and that fa lsification,
om issio n , or m isrep resentatio n is suff icient cause fo r disciplinary action, up to and incl uding term ination. I also
und e rsta nd tha t I am responsible for info rm ing m y superv isor in w riting if any info rm ation about m y outside em ploym ent
cha ng e s, espe cially if the re arises any possible confli ct of interest. Failure to do so m ay lead to disci plinary action,
in cl u d in g term in a tion of em ploym ent w ith the C ity of M iam i Beach. This request fo r approval of outside em ploym ent w ill
be m a d e on a yearly basis.
EMPLOYEE NAME.
Lo Me(ls
EMPLOYEE ID NUMBER:
2+(cv
EMPLOYEE SIGNATURE: f. . DATE: -
TO BE COMPLETED BY EMPLOYEE'S SUPERVISOR, DIVISION DIRECTOR, DEPARTMENT DIRECTOR
AND ASSISTANT CITY MANAGER
NAME OF SUPERVISOR Cos a Vezzo
NAME OF DIVISION DIRECTOR
Jose del R isco
NAME OF DEPARTMENT DIRECTOR
John R ebar
PLEASE CIRCLE ONE:
DISAPPROVED
PLEASE CIRCLE ONE: „eo IsAPRO V
PLEASE CIRCLE ONE:
APPkovED DISAPPROVED
HUMAN RESOURCES DIRECTOR
M arla A lpizar
PLEASE CIRCLE ONE:
APoveo DISAPPROVED
ASSISTANT CITY MANAGER
M ark Taxis
PLEASE CIRCLE ONE:
APPRvD DISAPPROVED
SUPERVISOR IG ATURE & DATE
'Go»
660l486,I IRE & DATE
7/6/2022 1 5:37 PM EDT
CTOR SIGNATURE & DATE
7/6/2022 I 5:57 PM ED T
CTOR SIGNATURE & DATE
y 7/6/2022 1 6:27 PM EDT
NAGER SIGNA TURE & DA TE
+.A Tc» 7/8/2022 \ 11:52 AM EDT
E9AC0518F2AA41A. ..
If yo u ha ve any questio ns regarding outside em ploym e nt, please contact the Hum an R esources D epartm ent at
30 5 .6 7 3 .7 5 24.
M:\$CMBIHUMARESO\OUTSIDE EMPLOYMENT Rvised 05162018.d0cx