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CITY OF MIAMI BEACH
REQUEST FOR APPROVAL OF OUTSIDE EMPLOYMENT
Page 1 of 2
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INFORMATION REGARDING CITY OF MIAMI BEACH CMB EMPLOYMENT
10 # DEPARTMENT I DIVISION
A.
EMPLOYEE NAME: LAST NAME, FIRST NAME, MIDDLE NAME
HOME PHONE #
JOB TITLE
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WORK PHONE #
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EMPLOYEE'S OTHER PHONE #s (BEEPER, CELL)
SUPERVISOR
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To BE COMPLETED By SUPERVISOR: Do YOU AGREE WITH THE
INFORMATION IN THIS SECTION? YES No
NORMAL WORK DAYS AND TIMES
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B. INFORMATION REGARDING OUTSIDE EMPLOYMENT
EMPLOYEE 10 # DEPARTMENT I DIVISION
NAME OF BUSINESS OR INDIVIDUAL HIRING CMB EMPLOYEE
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WORK PHONE # TYPE OF BUSINESS
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CITY STATE ZIP
DESCRIPTION OF DUTIES
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WHAT DUTIES MIGHT BE CONSIDERED TO BE A CONFLICT OF INTEREST i
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CITY OF MIAMI BEACH
REQUEST FOR APPROVAL OF OUTSIDE EMPLOYMENT - CONTINUED
PAGE 2 of 2
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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 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.
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By signing below, I certify that I have read this form completely and that I do not have any other employment 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.
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Employee Name
Employee ID Number
DATE
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II. TO BE COMPLETED BY EMPLOYEE'S CITY OF MIAMI BEACH DEPARTMENT
NAME OF SUPERVISOR
PLEASE CIRCLE ONE APPROVED
DISAPPROVED
SUPERVISOR SIGNATURE & DATE
NAME OF DIVISION HEAD
PLEASE CIRCLE ONE APPROVED
DISAPPROVED
DIVISION HEAD SIGNATURE & DATE
NAME OF DEPARTMENT DIRECTOR
PLEASE CIRCLE ONE APPROVED
DISAPPROVED
DEPARTMENT HEAD SIGNATURE & DATE
CITY MANAGER
PLEASE CIRCLE ONE AP
DISAPPROVED
CITY MANAGER SIGNATURE & DATE
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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 CMB EMPLOYMENT
10 # DEPARTMENT I DIVISION
EMPLOYEE NAME: LAST NAME. FIRST NAME, MIDDLE NAME
~Koo~5 \C.A Tl4 \ €. ~
\ 300"
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, CELL) I
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To BE COMPLETED By SUPERVISOR: Do YOU AG WI1S'HE l"T1
INFORMATION IN THIS SECTION? YES 0 co NO'
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SUPERVISOR
NORMAL WORK DAYS ANO TIMES
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B. INFORMATION REGARDING OUTSIDE EMPLOYMENT
EMPLOYEE 10 #
DEPARTMENT I DIVISION
NAME OF BUSINESS OR INDIVIDUAL HIRING eMB EMPLOYEE
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WORK PHONE # TYPE OF BUSINESS
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6!!';RK PHONE #
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CITY STATE ZIP
DESCRIPTION OF DUTIES
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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 2 of 2
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,
-Crthie "P-:>'LO~''S
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Employee Name
Employee 10 Number
q lIP Vb
e y:cc:.p C1S
D no~ on
. By signing below, I certify that I have read this form completely and that I do not have any other emPIOyment.G un~'G~ ~
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,
DATE
EMPLOYEE NAME
10 NUMBER
D,('CC'~S
II. TO BE COMPLETED BY EMPLOYEE'S CITY OF MIAMI BEACH DEPARTMENT
NAME OF SUPERVISOR
PLEASE CIRCLE ONE APPROVED
DISAPPROVED
SUPERVISOR SIGNATURE & DATE
NAME OF DIVISION HEAD
PLEASE CIRCLE ONE APPROVED
DISAPPROVED
DIVISION HEAD SIGNATURE & DATE
NAME OF DEPARTMENT DIRECTOR
PLEASE CIRCLE ONE APPROVED
DISAPPROVED
DEPARTMENT HEAD SIGNATURE & DATE
CITY MANAGER
PLEASE CIRCLE ONE
DISAPPROVED
Jo
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This form has 2 pages - be sure to
M:\$CMB\HUMARESOIOutside Employment Form 1006 03,doc
REV: 101D6/D3