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CITY OF MIAMI BEACH 2006 HaV 29 AM 9: IS
REQUEST FOR APPROVAL OF OUTSIDE EMPLOYMENT t..MqNCt~~ED
PAGE 2 of 2 "'S OFF ICE
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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.
EllIployee Name
(~/}y) /'7( .,~'.
Employee 10 Number
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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.
EMPLOYEE SIGNATURE
DATE
1'0 "OM'"
I EMecom "'M'
WITNESS SIGNATURE
II. TO BE COMPLETED BY EMPLOYEE'S CITY OF MIAMI BEACH DEPARTMENT
NAME OF SUPERVISOR
PLEASE CIRCLE ONE
DISAPPROVED
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NAME OF DIVISION HEAD '
t;(~.h,..... (Y"\ CG::N~::C"':e. II ~ S I Cb
PLEASE CIRCLE ON
NAME OF DEPARTMENT ,9IRECTOR DISAPPROVED
W,;t..s ~2'~r
PLEASE CIRCLE ONE
DISAPPROVED
M:\$CMB\HUMARESO\Outside Employment Form 1006 03.doc
SUPERVISOR SIGNATURE & DATE
REV: 10/06/03
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
INFORMATION REGARDING CITY OF MIAMI BEACH CMB EMPLOYMENT
ID # DEPARTMENT I DIVISION
EMPLOYEE NAME: LAST NAME, FIRST NAME. MIDDLE NAME /' .F':...'"- L. ~ p /)"
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,-,WORK PHONE # HOME PHONE #
A.
JOB TITLE, , /
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"WORK PHONE #
SUPj:RVISOR
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NORMAL WORK DAYS AND TIMES "
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B. INFORMA TION REGARDING OUTSIDE EMPLOYMENT
EMPLOYEE ID #
NAME OF BU~INESS.OR IND.IVIDUAL H1f3)N9 C~B E. M~L~jE_'.. ,__
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. - ~ - - - WORK PHONE #
JOB TITLE _' _ / ,/ ~__:..____
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SUPERVISO; J_'.L/' I: /:"')
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WORK PHONE #
NORMAL WORK o/'YS AND TIMES
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ADDRESS O~ BUSINESS: STREt=T
tllitf:!{ic.C/52 J?i
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STATE -fj
CITY
DESCRIPTION OF DUTIES
-I"l.. (.( e /; 1/11'
CT of INTEREST
WHAT DUTIES MIGHT BE CONSIDERED TO BE A CONFLI
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EMPLOYEE'S OTHER ~H~N~ #S (BEEPER, CELL)
7- f:':i/, ..5 C-i {. /j ,43-
... > ~:, - .....,.. . DO yOU AGREE WITH THE
To BE COMPLETED By SUPERVISflB;i.u......... YES No
INFORMATION IN THIS SECTION? ~-
DEPARTMENT I DIVISION
TYPE OF BUSINESS
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ZIP
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This form haS 2 pages - be sUre to Co b ges
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