Gómez, Susana Falero
.
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
/8"75/
WORK PHONE #
3D5'-&73-
7000 )(~~J
WORK PHONE #
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JOB TITLE
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SUPERVISOR
NORMAL WORK DAYS AND TIMES
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B.
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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DATE e~ I liRE
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JOB TITLE
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SUPERVISOR
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NORMAL WORK DAYS AND TIMES
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EMPLOYEE:? OTHER PHONE #s (BEEPER, CELL)
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To BE COMPLETED BY SUPERVISOR:
INFORMATION IN THIS SECTION?
No
DEPARTMENT I DIVISION
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ADDRESS OF BUSINESS: STREET / I S & N {; 10 I Sf,
CITY II/Oct .,' Sh Orli'JSTATE FL ZIP 3/ 3 Y
DESCRIPTION OF DUTIES / taJ ~~W.f- owl/1 t.-V/ t( cg,u ;r~ rL eel .e~+,-L #
?rok.c.fi'oY} - CJCCtA.SIOv!Cc.(J f:;elce 110Ju..Ct10~ 'Noyk --fOr Vt70-."-' DIAf'
tJSlA (A..( fl e rrfvr~,~'l. /)'1en+ nt" ~ I :f11er-v;c. vV 5'",J?iCc1S.
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
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.
Employee Name
Employee 10 Number
lf75
II-JO ~O(p
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.
if
,/
DATE
i)- 3 i/- D 6
EMPLOYEE NAME
SU.rO.J'1O- &kro
ID NUMBER
If7S/
II. TO BE COMPLETED BY EMPLOYEE'S CITY OF MIAMI BEACH DEPARTMENT
NAME OF SUPERVISOR
PLEASE CIRCLE 0
DISAPPROVE
SUPERVISOR SIGNATURE & DATE
NAME OF DIVISION HEAD
PLEASE CIRCLE ONE APPROVED
DISAPPROVED
NAME OF DEPARTMENT DIRECTOR
PLEASE CIRCLE NE APPROVED
DISAPPROVE
CITY MANAGER
PLEASE CIRCLE ONE A
DISAPPROVED
M:I$CMBIHUMARESOIOutside Employment Form 1006 03.doc
REV: 10/06/03