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Phillips, Steven Michael / CITY OF MIAMI BEACH REQUEST FOR APPROVAL OF OUTSIDE EMPLOYMENT Page 1 of 2 I. TQ 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 B. INFORMATION REGARDING OUTSIDE EMPLOYMENT EMPLOYEE 10 # DEPARTMENT I DIVISION ADDRESS OF BUSINESS: STREET ~ ..:;;2~O / 1)0 /VN ~cJi< ~. 'c2 IlESC'''PTIONOF 1lUTI~ ~ WHAT DUTIES MIGHT BE CONSIDERED TO BE A CONFLICT OF INTEREST N41I~ This form has 2 pages - be sure to complete both pages CITY OF MIAMI BEACH REQUEST FOR APPROVAL OF OUTSIDE EMPLOYMENT - CONTINUED PAGE 2 of 2 c. By signing below, I certify that all of the infonnation given on page one (1) of this document is true, accurate, and complete to the best of my knowledge. I understand that all infonnation 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 tennination of employment with the City of Miami Beach. This request for approval will be made on a yearly basis. Employee 10 Number D. By signing below, I certify that I have read this form comoletelv and that I do not have any other emOlovment. I understand that before I start any other employment, I must reauest and obtain the above aDorovals, I further understand that failure to comply with Outside Employment procedures could lead to disciplinary action up to and including tennination of my employment wit C' Of Miami Beach. ITNESS SIGNATURE II. TO BE COMPLETED BY EMPLOYEE'S CITY OF MIAMI BEACH DEPARTMENT NAME OF SUPERVISOR PLEASE CIRCLE ONE APPROVED DISAPPROVED SUPERVISOR SIGNATURE & DATE NAME OF DIVISION HEAD PLEASE CIRCLE ON DISAPPROVED t:r; /) )I~ NAME OF DEPARTMENT DIRECTOR PLEASE CIRCLE 0 DISAPPROVED U'-Z- This form has 2 pages - be sure to c M:\$CMB\HUMARESO\Outslde Employment Form 1006 OJ.doc REV: 10106I03 ----<~----_._-,-.""""""'...,.-=.-<<,,~;..."'.-,"'--.,~,.-,~....-_.,~"~'_'~_~""_"__""""'"~'-<'~"~'~~'__'="~~..~'._'U'~__ / 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 G/k-j~ I I ~ II) 305) cft/ - e!bS/ EMPLOYEE'S OTHER PHONE #s (BEEPER, CELL) NORMAL WORK DAYS A IMES /3; SA, B. INFORMATION REGARDING OUTSIDE EMPLOYMENT EMPLOYEE 10 # DEPARTMENT I DIVISION c~ TYPE OF BUSINESS /-i- / CITY g3/~ ~ ,,~~ , // /-'Y ...,.....~ DESCRIPTION OF DUTIES ~t0 ~~~/Vt1 RtlolVv- ~/t/N-:: )N..~)i . " . WHAT DUTIES MIGHT BE CONSIDERED TO BE A CONFLICT OF INTERESTN t//Y..t-- This form has 2 pages.... be sure to complete both pages ,~ CITY OF MIAMI BEACH REQUEST FOR APPROVAL OF OUTSIDE EMPLOYMENT - CONTINUED PAGE 2 of 2 c. By signing below, I certify that all of the infonnation given on page one (1) of this document is true, accurate, and complete to the best of my knowledge. I understand that all infonnation is subject to investigation and that falsification, omission. or misrepresentation is sufficient cause for disciplinary action, up to and including tennination. 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 tennination of employment with the City of Miami Beach. This request for approval will be made on a yearly basis. D. By signing below, I certify that I have read this fonn comoletelv and that I do not have any other emolovment. I understand that before I start any other employment, I must reQuest and obtain the above aODrovals, I further understand that failure to comply with Outside Employment procedures could lead to disciplinary action up to and including termination of my employment wit e i Miami Beach. ITNESS SIGNATURE II. TO BE COMPLETED BY EMPLOYEE'S CITY OF MIAMI BEACH DEPARTMENT NAME OF SUPERVISOR PLEASE CIRCLE ONE APPROVED DISAPPROVED SUPERVISOR SIGNATURE & DATE PLEASE CIRCLE 0 DISAPPROVE NAME OF DIVISION HEAD PLEASE CIRCLE ONE DISAPPROVED NAME OF DEPARTMENT DIRECTOR PLEASE CIRCLE 0 DISAPPROVED This form has 2 pages - be sure to. M:\$CMB\HUMARESo\Outside Employment Form 1006 OJ.doc REV: 10106I03