Osejo, Francisco Javier 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
WORK PHONE #
HOME PHONE #
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WORK PHONE #
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30
SUPE~OR
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NORMAL WORK DAYS AND TIMES
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To BE COMPLETED By SUPERVISOR: DO YOU AGREE WITH THE
INFORMATION IN THIS SECTION? ..>c-. YES NO
B.
INFORMATION REGARDING OUTSIDE EMPLOYMENT
EMPLOYEE 10 #
DEPARTMENT / DIVISION
NAME OF BUSINESS OR INDIVIDUAL HIRING CMB EMPLOYEE
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WORK PHONE #
TYPE OF BUSINESS
JOB TITLE
SUPERVISOR
DATE OF HIRE
NORMAL WORK DAYS AND TIMES
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CITY '- ~~, STATE ZIP C 3 \ ~ ,
DESCRIPTION OF DUTIES
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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
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 Name
Employee ID Number
1-3-0
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 d including termination of my
employment with the City Of Miami Beach.
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10 NUMBER
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II. TO BE COMPLETED BY EMPLOYEE'S CITY OF MIAMI BEACH DEPARTMENT
NAME OF SUPERVISOR
PLEASE CIRCLE ONE
DISAPPROVED
SUPERVISOR SIGNATURE & DATE
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NAME OF DIVISION HEAD
PLEASE CIRCLE ONE APPROVED
DISAPPROVED
DIVISION HEAD SIGNATURE & DATE
PLEASE CIRCLE ON
DISAPPROVED
TMENT HEAD SIGNATURE & DATE
------
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CITY MANAGER
PLEASE CIRCLE ONE APPROVED
DISAPPROVED
CITY MANAGER SIGNATURE & DATE
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This form has 2 pages - be sure to complete both pages
M:\$CMB\HUMARESO\Outside Employment Form 10 06 03.doc
REV: 10106/03
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