Abello, Digna
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
EMPLOYEE NAME: LAST NAME, FIRST NAME, MIDDLE NAME
~
Sb
WORK PHONE #
11.10
HOME PHONE #
JOB TITLE
30>,,"-111
WORK PHONE #
SUPERVISOR
&
NORMAL WORK DAYS AND TIMES
f'f OCOO#~OO
B.
INFORMATION REGARDING OUTSIDE EMPLOYMENT
EMPLOYEE ID #
DEPARTMENT I DIVISION
NAME OF BUSINESS OR INDIVIDUAL HIRING CMB EMPLOYEE
JOB TITLE
~M'OIL
'OS.11 . ,,'is)
WORK PHONE #
aoC;Y11 .~'i~1
DATE OF HIRE
NORMAL WORK DAYS AND TIMES
ADDRESS OF BUSINESS: STREET c..
~'I\~^-Y
12. $; N v-J \~ CITY
STATE F\
ZIP
,~\u,.
DESCRIPTION OF DUTIES
As~~ tz.Itl ~t~ ~ "teVAt1Jll.~ ~O &\~. ~DVCK\~ ~LO~ ~~ r~~(L
N~'~ fOlLMAT.IrS.S\J(ZC. ~~....~ CotAVU~ ~ fou.9we:.t> ~~~ ~'-~b (>.....~N"t
~ b.NO ~lf\lb (a.\I~ ~.
~
/k~,$I RP~"// ......
This form has 2 pages - be sure to co
" ~,."_._............._~~,.~~"'~~______..............._.._"'~._~~"-'--~_._~.~.-..."....._.~',,-,,_,,~',u"""""'"'''''~'~
. .
CITY OF MIAMI BEACH
REQUEST FOR APPROVAL OF OUTSIDE EMPLOYMENT - CONTINUED
PAGE2of2
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.
1 S
EjPI~ee signature & Date
. \ rz. 2.DOS
Employee Name
Employee ID Number
D.
By signing below, I certify that I have read this form completely 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.
.('2.' OC;
~
DATE
10 NUMBER
\\0
1~'S~
II. TO BE COMPLETED BY EMPLOYEE'S CITY OF MIAMI BEACH DEPARTMENT
PLEASE CIRCLE 0
DISAPPROVE
SUPERVISOR SIGNATURE & DATE
PLEASE CIRCLE 0
NAME OF SUPERVISOR DISAPPROVED
t'HA.'Es"'r~ A lkltll'YS
NAME OF DIVISI~EAD
JE:FfE12-Y J)uc~ wDl2.ir\
PLEASE CIRCLE 0
DISAPPROVED
NAME OF DEPARTMENT DIRECTOR
PLEASE CIRCLE ONE
DISAPPROVED
~--v--
This form has 2 pages - be sure to c;o
I
M:\$CMB\HUMARESO\Outside Employment Form 1006 03.doc
REV: 10/06103