Rios, Edwin N. 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 I DIVISION
WORK PHONE #
To BE COMPLETED BY SUPERVISOR: Do YOU AGREE WITH THE
INFORMATION IN THIS SECTION? YES No
EMPLOYEE NAME: LAST NAME, FIRST NAME, MIDDLE NAME
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B.
INFORMATION REGARDING OUTSIDE EMPLOYMENT
EMPLOYEE ID #
DEPARTMENT f DIVISION
NAME OF BUSINESS OR INDIVIDUAL HIRING eMB EMPLOYEE
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WORK PHONE #
TYPE OF BUSINESS
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WORK PHONE #
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This form has 2 pages - be sure 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 signature & Date
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 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.
EMPLOYEE SIGNATURE
DATE
WITNESS SIGNATURE
I E"PLOY<< NAM'
I'D No""",
II. TO BE COMPLETED BY EMPLOYEE'S CITY OF MIAMI BEACH DEPARTMENT
PLEASE elRCLE ONE APPROVED SUPERVISOR SIGNATURE & DATE
NAME OF SUPERVISOR DISAPPROVED
PLEASE elRCLE ONE APPROVED DIVISION HEAD SIGNATURE & DATE
NAME OF DIVISION HEAD DISAPPROVED
PLEASE elRCLE ONE APPROVED DEPARTMENT HEAD SIGNATURE & DATE
NAME OF DEPARTMENT DIRECTOR DISAPPROVED
PLEASE CIRCLE ONE APPROVED elTY MANAGER SIGNATURE & DATE
elTY MANAGER DISAPPROVED
This form has 2 pages - be sure to complete both pages
M:\$eMB\HUMARESO\Outside Employment Form 1006 03.doc
REV: 10/06/03