Olson, Jamie Marie
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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 (eMB) EMPLOYMENT
10 # DEPARTMENT I DvISION
JOB TITLE
t-tlRMAL \/"bRK l)It.YS AND TIMES
820-5'00
B.
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G
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HoME A-iONE #
q~-.3=14-9~
EMPLOYEE'S
R A-iONE #S (Ba:PER, CELL)
~~
TO BE COMPLETED By t.f'ERVISOR;~PU AGREE WITH THE
INFDRMA TION IN THIS SECTION 1 . YES No
INFORMATION REGARDING OUTSIDE EMPLOYMENT
EMPLOYEE ID #
DEPARTMENT I DvISION
~ME OF BUSINESS OR NDIVIDUAL tiRING CM3 EMPLOYEE
Na.c I~
JoB TITlE
~e'S. __..\'SSc.C~LL.\e-
SUPERVISOR
o -e \ i a.. ~ \ lQ.,d.-
t-tlRMAL \/"bRK l)It.YS AND TIMES
5:2:(:) -=t:1 \ '."2:CJ
ADDRESS OF 9.JSINESS: STREET
WORK A-iONE #
r~
\/"bRK A-toNE #
~"'=t<l.(g2~
I)It.TE OF tiRE
2/ 11/00
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DESCRIPTION OF OJTIES
ZIp .361
r e\cU \
N./A
WiAT [)JrIES MGHT BE CoNSIDERED TO BEA CoNFLICT OF NTEREST
This form has 2 pages - be sure to 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.
Employee Name
~~ Orof\.-
Employee 10 Number
Employee signature & Date
. \1-~
D.
By signing below, I certify that I have read this form comDletelv 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 aoorovals, 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
2/9
WITNESS SIGNATURE
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II. TO BE COMPLETED BY EMPLOYEE'S CITY OF MIAMI BEACH DEPARTMENT
~ME OF SJPERVlSOR
R.EASE ORCLE ONE APPROVED
DISAPPROVED
SUPERVISOR SIGNATURE I)It.TE
~ME OF DIVISION l-EAD
R.EASE ORCLE ONE APPROVED
DISAPPROVED
DIVISION l-EAD SIGNATURE & I)It.TE
NAME OF !:ePARTMENT DIRECTOR
REASE ORClE ONE
DISAPPROVED
f;1:Z=&~
OTY MwAGER SIGNATURE &I)It.TE
R.EASE ORClE ON
DISAPPROVED
UI~L
This form has 2 pages - be sure to C'1"Ple
M\$CMB\HUMARESO\Outside Employment Fonn 1006 03.doc
REV: 10/06/03