Fernandez, Jorge
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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
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WORK PHONE # HOME PHONE #
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EMPLOYEE'S OTHER PHONE #S (BEEPER, CELL)
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To BE COMPLETED By SUPERVISQf1: DO/O~~~EE WITH THE
INFORMATION IN THIS SECTION? ~ No
B.
INFORMATION REGARDING OUTSIDE EMPLOYMENT
EMPLOYEE 10 #
DEPARTMENT I DIVISION
WORK PHONE #
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WORK PHONE #
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CITY \ Iv\. \.
DESCRIPTION OF DUTIES ~ & pEC:X B-ENA\ 0 Q.5
STATE L ZIP 330 \ 5
a0\S.ft~~ ~E d1i of N.\~\g~
WHAT DUTIES MIGHT BE CONSIDERED TO BE A CONFLICT OF INTEREST N [) ~ t;
This form has 2 pages - be sure to complete both pages
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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,
D.
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.
II. TO BE COMPLETED BY EMPLOYEE'S CITY OF MIAMI BE
EPARTMENT
NAME OF DEPARTMENT DIRECTOR
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PLEASE CIRCLE ONE
DISAPPROVED
ATURE & DATE
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D"AAi:'^"':'^J~ yO
NAME OF SUPERVISOR
10th) AN1o.,)A
NAME OF DIVISION HEAD 1\
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PLEASE CIRCLE 0
DISAPPROVED
PLEASE CIRCLE ON
DISAPPROVED
This form has 2 pages - be sure t
M:\$CMB\HUMARESO\Outside Employment Form 1006 03.doc
REV: 10/06/03