Pereny, Charles A.
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 SEACH (CMS) EMPLOYMENT
10 # DEPARTMENT I DIVISION
JOB TITLE
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WORK PHONE #
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WORK PHONE
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HOME PHONE # 17.)
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EMPlOYEE'S OTHER PHONE #S (BEEPER, CELL)
SUPERVISOR
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To BE COMPLETED BY SUPERVISOR: Dq)tou AGREE WITH THE
INFORMATION IN THIS SECTION? ~ YES No
NORMAL WORK DAYS AND TIMES
NAME OF BUSINESS OR INDIVIDUAL HIRING CMB EMPLOYEE
INFORMATION REGARDING OUTSIDE EMPLOYMENT
EMPLOYEE 10 #
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DEPARTMENT I DIVISION
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SUPERVISOR
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TYPE OF BUSINESS
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JOB TITLE
NORMAL WORK DAYS AND TIMES
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ADDRESS OF BUSINESS: STREET
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DESCRIPTIONOFDUTlfS ~f(C>.p.cvi ~ )~'i€. of- PIa/tc/"" I A.; '6hdl rte~t>"'iX ~/lA-1 J .
WHAT DUTIES MIGHT BE CONSIDERED TO BE A CONFLICT OF INTEREST
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This form has 2 pages - be sure to comp e
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 ifthere 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 10 Number
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.
DATE
1 {I/o 5
I--N-
U^l4ld e J PL({~'^1
I "' NUMBER
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II. TO BE COMPLETED BY EMPLOYEE'S CITY OF MIAMI BEACH DEPARTMENT
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NAME OF SUPERVISOR
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PLEASE CIRCLE E APPROVED
DISAPPRO
SUPERVISOR SIGNATURE & DATE
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PLEASE CIRCLE ONE
DISAPPROVED
PLEASE CIRCLE ONE APPROVED .
DISAPPROVED
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This form has 2 pages - be sure to complet~
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