Ramirez, Otto Jesus
CITY OF MIAMI BEACH
REQUEST FOR APPROVAL OF OUTSIDE EMPLOYMENT
Page 1 of 2
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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
EMPLOYEE NAME: LAST NAME, FIRST NAME, MIDDLE NAME
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SUPERVISOR
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NORMAL WORK DAYS AND TIMES .J)+1i=:r v.i,) f?~ \c.
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WORK PHONE #
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WORK PHONE #
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HOME PHONE #
JOB TITLE
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EMPLOYEE'S OTHER PHONE #s (BEEPER, E
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To BE COMPLETED By SUPERVISOR: Do 1(!JtEE WITH THE
INFORMATION IN THIS SECTION? Y No
B.
INFORMATION REGARDING OUTSIDE EMPLOYMENT
EMPLOYEE ID #
DEPARTMENT I DIVISION
NAME OF BUSINESS OR INDIVIDUAL HIRING CMB EMPLOYEE
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JOB TITLE
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SUPERVISOR
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TYPE OF BUSINESS
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ADDRESS OF BUSINESS: STREET
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DESCRIPTION OF DUTIES Olc"""i2 Pr17 J ~ () ~ ,A- t{-'((Jr:;%2 0.~\ c.. C ~~ G.tfyt:~ Fd!.!-
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WHAT DUTIES MIGHT BE CONSIDERED TO BE A CONFLICT OF INTEREST
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This form has 2 pages - be sure to complete both pages
CITY OF MIAMI BEACH
REQUEST FOR APPROVAL OF OUTSIDE EMPLOYMENT - CONTINUED
PAGE 2of2
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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 difciplinary q/:;tion. up to and including termination. I also understand
that I am responsible for informing my supervisor 'in writing it ctny information about rryy outside ..employment changes,
especially if there arises any possible conflicfof interest. .Failure to do so may lead to disciplinary action, including termination
of employment with the City of Miami Beach. This reqtJest for approval will be made on a yearly basis.
Employee Name
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Employee 10 Number
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Employee signa
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By signing below, I certify that I have read this form completelv and that I do not have an other
that before I start any other employment, I must request and obtain the above approvals, I furt r erstand that failure to
comply with Outside Employment procedures could lead to disciplinary act" n up to an . eluding termination of my
employment with the City Of Miami Beach.
EMPLOYEE NAME
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DATE
EMPLOYEE SIGN
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II. TO BE COMPLETED BY EMPLOYEE'S CITY OF MIAMI BEACH OEP
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This form has 2 pages - be sure to c
PLEASE CIRCLE ON
DISAPPROVED
NAME OF SUPERVISOR
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NAME OF DIV~N HEAD
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NAME OF DEPARTMENT DIRECTOR
CITY MANAGER
PLEASE CIRCLE ONE
DISAPPROVED
M:\$CMB\HUMARESO\Outside Employment Form 1006 03.doc
REV: 10/06/03
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