Prieto, Silvia
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
ID # ~~EPA~TMENTWI DIVIS610No~/
EMPLOYEE NAME: LAST NAME, FIRST NAME, MIDDLE NAME ' ,
I '3? I Y
HOME HONE #
)1
305- 7S'/--P3'-fJJ
EMPLOYEE'S OTHER PHONE #S (BEEPER, CELL)
To BE COMPLETED BY SUPERVISOR: Do YOU AGREE WITH THE
INFORMATION IN THIS SECTION? YES No
MC>AJ~A
B.
INFORMATION REGARDING OUTSIDE EMPLOYMENT
EMPLOYEE ID #
DEPARTMENT I DIVISION
-::J.,J:S
'fnIM)J(j. I~ -
IUd
WORK PHONE #
St;".t
77b' D~C.s
WORK PHONE #
${"I-
99god-.D 5
DATE OF HIRE
!}
/193
ADDRESS OF BUSINESS: STREET. : J
I II D t' ;0_ C11 () P A j}rt4! S.L~.q f I;) S- . cL. 3 '., li..p 7 i\. 7
/::1 ( ..,) L.{),1 ~v CITY f 1;> c ,. elL-STATE I ZIP'::> { - 2..-:'S" 2-
DESCRIPTION OF DUTIES C;tZ.~C{, .JNt€.R. evltft oAJJ1 L i,Ult I" s: - b/r!2-Ec.f/~1
17 N tJ 4s 5;:'; iril7---" ~v.~ I, 'I (, ( :",/1 (l i';'," )'0 fc ct. ~~ L)
(012.- fCu.- <;:;),C'I.{< I dS ~\, L.--L.( if>)('Z'ft[,,1,-/,L.~
WHAT DUTIES MIGHT BE CONSIDERED TO BE A CONFLICT OF INTEREST 'rvo ~ . ~ Lt....; ~ ~(. ~
~l ~~. ~.~~9-f~_
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 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 D
51), vi ~ 11Z'1 Eil)
Employee ID Number
~ 137/ i
Employee signature &
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 and including termination of my
employment with the City Of Miami Beach.
WITNESS SIGNATURE
;
EMPLOYEE NAME 0
5'),LI/IA l~/&"fD
ID NUMBER
137/'1
II. TO BE COMPLETED BY EMPLOYEE'S CITY OF MIAMI BEACH DEPARTMENT
PLEASE CIRCLE ONE APPROVED
DISAPPROVED
SUPERVISOR SIGNATURE & DATE
G #J" 6~12 'ld
PLEASE CIRCLE ONE
DISAPPROVED
IYI't/nI b~ Utf~
PLEASE CIRCLE ONE
DISAPPROVED
This form has 2 pages - be sure to
M:\$CMB\HUMARESO\Outside Employment Form 1006 03.doc
REV: 10106/03
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
ID # DEPARTMENT I DIVISION
STATE -L ZIP 33/3'/
flt.Jt;; ;;j~IAJ~).fC-1 51'7/.-[7>) ~N VE:/Ufo'l'
~ ~ pe~~/J~J fk Se-IV~ ~~ .~"E
Qp(t\Q--, 4 i M e-d. 6'e..;r Y' Se. t v f fu ;tfrlfj,t.-( ~?f<.. 1-4 f ~ ~
WHAT DUTIES MIGHT BE CONSIDERED TO BE A CONFL,I,CT OF INTEREST \., 0 n €:.. - /11 f- ~ ~ ~ . 4
wd-e ~ I (2~ ~" ~~
EMPLOYEE NAME: LAST NAME, FIRST NAME, MIDDLE NAME
g iii f:: b SJ).. V I R I "3 7 / C;
v5 ()Me/2 See-VIe WORK PHONE #
JOB TITLE ,,()
/JPM j}r!;>!! ;r-- f \.t;?' b73~;f7- 6
WORK PHONE #
SUPERVISOR d / d / \ _ L h73 tpo t:>
/;:;?4"'vA-~/f ttflt{.;:I'f C'I'C Ex "'177
NORMAL WORK DAYS AND TIMES
W]O,() D - F A.. I
i?3o A-~ - 5; 10 t11 .
B.
INFORMATION REGARDING OUTSIDE EMPLOYMENT
EMPLOYEE ID #
IS ~ '7 "1 J- t,
JOB TITLE I
5'!J {,,- E <;
WORK PI-!.QNE #
,,?(J ~ -
h7'1- 6;)..75
SUPERVISOR ~ c)/ff fo LLo/{'"
vJU-
NORMAL WORK DAYS AND TIMES SM- D p- go N .
/VJO/IJD - we&. ~'30 - ~',3 0
'/IN $"WE~ CL~
h
HOME PHONE #
3oS- 7~/- J'3 Lj P
EMPLOYEE'S OTHER PHONE #s (BEEPER, CELL)
To BE COMPLETED By SUPERVISOR: Do YOU AGREE WITH THE
INFORMATION IN THIS SECTION? YES No
DEPARTMENT I DIVISION /J ~ -IJ. .
Flit) ~ .:re l.U12. f;Z 'I ~-f"'-t:
TYPE OF BUSINESS
~€.f/!;L
I-
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 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
'oJ/tv/it
Employee ID Number
1'37/f(
EmPI~a~
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 and including termination of my
employment with the City Of Miami Beach.
E1'~d
WITNESS SIGNATURE
EMPLOYEE NAME
'S II-viA
ID NUMBER
,tel e-fo
137 (
II. TO BE COMPLETED BY EMPLOYEE'S CITY OF MIAMI BEACH DEPARTMENT
NAME OF SUPERVISOR
01112blllll
PLEASE CIRCLE ONE APPROVED
DISAPPROVED
SUPERVISOR SIGNATURE & DATE
D
DATE
! ,Yt/1-0 0r,f-v.-lM
\ - s.,) ()
ffl ~?
M:\$CMB\HUMARESO\Outside Employment Form 1006 03.doc
REV: 10106/03