LeCounte, Sonia
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RECEIVED
CITY OF MIAMI BEACH 2007 FEe _
REQUEST FOR APPROVAL OF OUTSIDE EMPAuOYMENT 8 AM 9: 08
Page 1 of 2 MAN RESOURCES. C/'lo
I. TO BE COMPLETED BY EMPLOYEE - This Form must be completed & approved prior to
beginning any other employment
INFORMA TION REGARDING CITY OF MIAMI BEACH CMB EMPLOYMENT
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WORK PHONE #
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WORK PHONE #
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NORMAL WORK DAYS AND TIMES
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INFORMATION REGARDING OUTSIDE EMPLOYMENT
EMPLOYEE 10 #
NAME OF BUSINESS OR INDIVIDUAL HIRING CMB EMPLOYEE
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WORK PHONE #
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WORK PHONE #
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NORMAL WORK DAYS AND TIMES
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ADDRESS OF BUSINESS: STREE~ J
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DESCRIPTION OF DUTIES
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WHAT DUTIES MIGHT BE CONSIDERED TO BE A CONFLICT OF INTEREST
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HOME PHONE #
To BE COMPLETED By SUPERVISOR: Do YO GREE WITH THE
INFORMATION IN THIS SECTION? YES No
DEPARTMENT I DIVISION
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TYPE OF BUSINESS
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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 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. This request for approval will be made on a yearly basis.
EmPire:; 535
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
employm nt :lith the Cit ~f Miami B{:1€!}'
DATE
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EMPLOYEE NAME
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NAM'O:~;;;'~
PLEASE CIRCLE
DISAPPROVED
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NAME OF DIVISION HEAD
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PLEASE CIRCLE ON
DISAPPROVED
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This form has 2 pages - be sure to
M:\$CMB\HUMARESO\Outside Employment Form 1006 03.doc
REV: 10/06/03