Hasbun, Jorge 2005
CITY OF MIAMI BEACH
REQUEST FOR APPROVAL OF OUTSIDE EMPLOYMENT
Page 1 of 2
I. TO BE COMPLETED BY EMPLOYEE - This Form must be completed & approved prior to
beginning any other employment
A. INFORMATION REGARDING CITY OF MIAMI BEACH CMB EMPLOYMENT
ID # DEPARTMENT I DIVISION
~TNAME'FI~;~EAME
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HOME PHONE #
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JOB TITLE
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WORK PHONE #
305
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WORK PHONE #
J305--b73
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305 I'a? o/'~~I
EMPLOYEE'S OTHER PHONE #S (BEEPER, CELL)
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7/D f't::;
No
NORMAL WORK DAYS AND TIMES
S/lr- we~, .930
To BE COMPLETED BY SUPERVISOR: Do
INFORMATION IN THIS SECTION?
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B.
INFORMATION REGARDING OUTSIDE EMPLOYMENT
EMPLOYEE ID #
DEPARTMENT I DIVISION
USINESS OR INDIVIDUAL HIRING CMB EMPLOYEE
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yEs
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WOR~PHONE # TYPE OF BUSINESS
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q~7 /305 C! /
JOB TITLE
SUPERVISOR
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7 I 30~
DATE OF HIRE
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NORMAL WORK DAYS AND TIMES
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ADDRESS OF BUSINESS: STREET
DESCRIPTION OF DUTIES
/J~ STATE
ZIP
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REC~l~iR
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WHAT DUTIES MIGHT BE CONSIDERED TO BE A CONFLICT OF INTEREST
No Af6 .
This form has 2 pages - be sure to complete both pages
'CITY OF MIAMI BEACH
REQUEST FOR APPROVAL OF OUTSIDE EMPLOYMENT - CONTINUED
PAGE 2 of 2
c.
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 will be made on a yearly basis.
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Employee 10 Number
I C- (2:>
D.
By signing below, I certify that I have read this form completelv and that I do not have anv other emplovment. I understand
that before I start any other employment, I must request and obtain the above approvals, I further understand that failure to
comply with Ou side ployment procedures could lead to disciplinary action up to and including termination of my
employment . the . y Of Miami Beach.
WITNESS SIGNATURE
b~
10 NUMBER
t c, toG :;r
II. TO BE COMPLETED BY EMPLOYEE'S CITY OF MIAMI BEACH DEPARTMENT
PLEASE CIRCLE ON
DISAPPROVED
y 17/05
PLEASE CIRCLE ON
DISAPPROVED
PLEASE CIRCLE ONE APPROVED
DISAPPROVED
PLEASE CIRCLE ONE AR
CITY MANAGER DISAPPROVED
~'2?k1-
This form has 2 pages - be sure to c
M:I$CMBIHUMARESOIOutside Employment Form 1006 03.doc
REV: 10/06/03