Jay, Lisa Ann Inc.
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
INFORMATION REGARDING CITY OF MIAMI BEACH (CMB) EMPLOYMENT
ID # DEPARTMENT I DIVISION .'
/1'576 jilfm r-!ff/(/ftt-fIOIj -
A.
EMPLOYEE NAME: LAST NAME, FIRST NAME, MIDDLE NAME
:111 LISA frNN
JOB TITLE 6 U (J Elf V/ XJf!. I
SUPERVISOB...; I / /1 P /: /7 0
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NORMAL WORK DA~ND TIMES
/J1-F y-590
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WORK PHONE #
(Y}':)-
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B. INFORMATION REGARDING OUTSIDE EMPLOYMENT
EMPLOYEE ID#
NAME OF BUSINESS OR INDIVIDUAL HIRING CMB EMPLOYEE
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/f;fHator'- tJdtu2tor
~,~~VISOR f2 ./
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f-OBJt/J~ #
969-2L/W
7~R~!E#
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DATE OF HIRE
/9?JS
HOME PHONE #
~-05;2-.(65-{)
EMPLOYEE'S OTHER PHONE #s (BEEPER, CELL)
7gra-(25/~Oogl
To BE COMPLETED BY SUPERVISOR: Do.)'ou AGREE WITH THE
INFORMATION IN THIS SECTION? Y YES No
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TYPE OF BUSINESS
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ADDRESS OF BUSINESS: STREET
~/Ja c/lltSl-er" HI/C fa Ire WYI/; fL 33LI67
.../, CITY STATE ZIP
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WHAT DUTIES MIGHT BE CONSIDERED TO BE A CONFLICT OF INTEREST
This form has 2 pages - be sure to complete both pages
CITY OF MIAMI BEACH
REQUEST FOR APPROVAL OF OUTSIDE EMPLOYMENT - CONTINUED
PAGE2of2
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.
EJPloyee Namn '/7"
/..../50 (.1', V'OC
Employee 10 Number
/7':>7;0
D.
By signing below, I certify that I have read this form completely and that I do not have any other employment. 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 Outside Employment procedures could lead to disciplinary action up to and including termination of my
employment with the City Of Miami Beach.
EMPL,OYE~IGN~~E 't:?)f I /
[1']::1 u. V-I'V
DATE 1(; 9/05'" WITNESS SIGNATURE
EMPLOYEE NAME,/') '"7/)' ,
i( Sa, c7' JUl
10 NUMBER
1757Z~
II. TO BE COMPLETED BY EMPLOYEE'S CITY OF MIAMI BEACH DEPARTMENT
PLEASE CIRCLE ONE APPROVED
DISAPPROVED
~\T,DA"~
ION HEAD SIGNATURE & DA
NAME OF.DIVISI9!")XEAD 'n()
JU/;6 Ill) (/9::::
PLEASE CIRCLE ONE APPROVED
DISAPPROVED
If; 0;?ARg(;;7fh
PLEASE CIRCLE ONE APPROVED
DISAPPROVED
DEPARTMENT HEAD SIGNATURE & DATE
:~. ./.) / PLEASE CIRCLE ONE APPROVED
~ct0/7Zcd'c~ DISAPPROVED
This form has 2 pages - be sure to complete both pages
CITY MANAGER SIGNATURE & DATE
M:\$CMB\HUMARESO\Outside Employment Form 1006 03.doc
REV: 10/06/03