Munoz, Carlos Alberto 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
A. INFORMATION REGARDING CITY OF MIAMI BEACH CMB EMPLOYMENT
10 # DEPARTMENT / DIVISION
EMPLOYEE NAME: LAST NAME, FIRST NAME, MIDDLE NAME
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JOB TITLE
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SUPERVISOR
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NORMAL WORK DAYS AND TIMES
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WORK PHONE #
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WORK PHONE #
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B.
INFORMATION REGARDING OUTSIDE EMPLOYMENT
EMPLOYEE 10 #
JOB TITLE
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NORMAL WORK DAYS AND TIMES
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ADDRESS OF BUSINESS: STREET
WORK PHONE #
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WORK PHONE #
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DATE OF HIRE
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HOME PHONE #
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EMPLOYEE'S OTHER PHONE #s (BEEPER, CELL)
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To BE COMPLETED BY SUPERVlSQfj: f!!'U AGREE WITH THE
INFORMATION IN THIS SECTION? ~ YES No
DEPARTMENT / DIVISION
TYPE OF BUSINESS
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CITY
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DESCRIPTION OF DUTIES
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WHAT DUTIES MIGHT BE CONSIDERED TO BE A CONFLICT OF INTEREST
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This form has 2 pages - be sure to complete both pages
CITY OF MIAMI BEACH
REQUEST FOR APPROVAL OF OUTSIDE EMPLOYMENT - CONTINUED
PAGE 2 of2
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.
Employee 10 Number
:s Y 2-0
D.
By signing below, I certify that I have read this form completelv and that I do not have any other emplovment. I understand
that before I start any other employment, I must reauest 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.
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EMPLOYEE NAME
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ID NUMBER
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II. TO BE COMPLETED BY EMPLOYEE'S CITY OF MIAMI BEACH DEPARTMENT
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PLEASE CIRCLE ON
DISAPPROVE
NAME OF'fi UPERVISOR PIAIIf)
NAME OF DEPARTMENT DIRECTOR
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CITY MANAGER
PLEASE CIRCLE ONE APPROVED
DISAPPROVED
This form has 2 pages - be sure to complete both pages
M:\$CMB\HUMARESO\Outside Employment Form 10 06 03.doc
REV: 10/06/03
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