Taylor, Elise Spina
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CITY OF MIAMI BEACH " ,-
REQUEST FOR APPROVAL OF OUTSIDE EMPl$'tfWIJUI1 M1 7: 44
Page 1 of 2 r.' 1..'I;~'S @FFICE
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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# S-93/ DEPARTMENT I DIVISION
EMPLOYEE NAME: LAST NAME, FIRST NAME, MIDDLE NAME PO//C e /c r,'/h I>)({ I '''1 vfff,'.ftll,o....
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JOB TITLE
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WORK PHONE # EMPLOYEE'S OTHER PHONE #s (BEEPER, CELL)
SUPERVISOR (P6R)
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To BE COMPLETED By SUPERVISORI"/'.U AGREE WITH THE
NORMAL WORK DAYS AND TIMES INFORMATION IN THIS SECTION? YES No
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B. INFORMATION REGARDING OUTSIDE EMPLOYMENT
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DEPARTMENT I DIVISION I I
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TYPE OF BUSINESS
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EMPLOYEE 10#
NAME OF BUSINESS OR INDIVIDUAL HIRING CMB EMPLOYEE
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WORK PHONE #
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WORK PHONE #
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SUPERVISOR
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DATE OF HIRE /"1.
NORMAL WORK DAYS AND TIMES D 0 f S NO f Co /\ I 1- c-l
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ADDRESS OF BUSINESS: STREET ~ Ol 00 /V ty '/ ~ A v f...., vel U -1 l"-f 4
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CITY Fh I a />"11 STATE ;=:L ZIP 3.3 I ~ ")
D~SCRIPTIONOFDUTIES ?rov,'c/e d,"CI.9l'1oShc.. q"c! for(7,..,~;'~ e :Qlvc; 1->0'"5)
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WHAT DUTIES MIGHT BE CONSIDERED TO BE A CONFLICT OF INTEREST
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CITY OF MIAMI BEACH
REQUEST FOR APPROVAL OF OUTSIDE EMPLOYMENT - CONTINUED
PAGE 2 of 2
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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 Name
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Employee 10 Number
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By signing below, I certify that I have read this form completely and that I d not have an other em 10 ment. 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.
DATE
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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
PLEASE CIRCLE ONE
DISAPPROVED
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PLEASE CIRCLE ON
DISAPPROVED
PLEASE CIRCLE ONE
NAME OF DEPARTMENT DIRECTOR DISAPPROVED
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PLEASE CIRCLE ONE APPROVED
DISAPPROVED
CITY MANAGER SIGNATURE ~~ATE
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This form has 2 pages - be sure to qt>,
both pages
M:\$CMB\HUMARESO\Outside Employment Form 1006 03.doc
REV: 10/06/03