Adkinson, Cheryl Dee
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 / DIVISION
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EMPLOYEE'S Of HER PrlONE #S (B=:EPER, CELL)
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B.
INFORMATION REGARDING OUTSIDE EMPLOYMENT
EMPLOYEE 10 #
DEPARTMENT / DIVISION
E OF BUSINESS OR INDIVIDUAL HIRING CMB EMPLOYEE
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TYPE OF BUSINESS
JOB TITLE
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DATE OF HIRE
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WHAT DJTIES MIGHT BE CONSIDERED TO BEA CONFLICT OF INTEREST II.. ()vUl.-
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
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Employee ID Number
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D.
By signing tie low, I certify that I have read this form cDmpletelv and that I do not have any other employment. I understand
that before I ~tGlrt any other employment, I must reauest 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
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DATE
3
W(7 SIGNATURE
IDNuMBER
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II. TO BE COMPLETED BY EMPLOYEE'S CITY OF MIAMI BEACH DEPARTMENT
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REASE ORCLE ONE
DISAPPROVED
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REASE ORCLE ONE APPROVED
DISAPPROVED
This form has 2 pages - be sure to complete both pages
M:\$CMB\HUMARESO\Outside Employment Form 10 06 03.doc
REV 10/06/03