Brooks, Kathie, Gene Form 1F'v ~ -'t =1. v ~ L
CITY OF MIAMI BEACH `_ ~
REQUEST FOR APPROVAL OF OUTSIDE EMPLOYMENT ap. ~
Page 1 of 2 ~ ~ "'
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I. TO BE COMPLETED BY EMPLOYEE -This Form must be completed & approvecnoC.ao
beginning any other employment ~` „~..
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A_ WF~RMATI~N REGARnINr CITV AF M/dM/ RFd!`il /rMCa!1 cMVi nvMCAIT
ID # DEPARTMENT /DIVISION
EMPLOYEE NAME: LAST NAME, FIRST NAME, MIDDLE NAME
~ooKS, KATi-t I~ CTG-..1 C-. l~(~O(,~ BJnC~6T• ~ P62RVRH rM1C-. tMP.
WORK PHONE # HOME PHONE #
JOB TITLE
Die ~ G'ro2 305'-6?3.?ct 30 ~ - g~? - 7g7~
WORK PHONE # EMPLOYEES OTHER PHONE #S (BEEPER, CELL)
SUPERVISOR
'Tcxt..Gr~ Czo N Zli~-E Z s - 6'131ao 30 ~ - 3 ~~ -~ B ? 6
TO BE COMPLETED BY SUPERVISOR: DO YOU AGREE WITH THE
NORMAL WORK DAYS AND TIMES INFORMATION IN THIS SECTION? YES NO
MON D AEI - F2- D A~ ~ 9 A~`l -i
B_ INFORMATIAN RFPORIIINC nLlTCInF FMD/ nyMCA1T
EMPLOYEE ID # DEPARTMENT /DIVISION
NAME OF BUSINESS OR INDIVIDUAL HIRING CMB EMPLOYEE
~tL tNT~~e..-JAnp~JA~ 2bp-`~ --- ..-'
WORK PHONE # TYPE OF BUSINESS
JOB TITLE
SI~LGS ASSacaA"~E. -' -4.GA~ E.STAz'C-.
WORK PHONE #
SUPERVISOR
1~ P1~J ~ ~. L gAv- A Q.oRR 3DS- 6'?y -1 9
DATE OF HIRE
NORMAL WORK-DAYS AND TIMES
tv~,N t ~+~ ~ -r~s ~ E~ aE ,~ a o0 3
ADDRESS OF BUSJNL'SS: STREET I g ~ ~ S V N s L T -+ ~2. $ o e ~ R t v E
CITY l'1 tAN, ~'f1C.~ STATE ~~'- ZIP ~ ~ , ~ v
DESCRIPjIONOPDUTIES -
---av"- ~.--~ s~. ~-~ ~ a ~ e.E~ ~ EST AT6
WHAT DUTIES MIGHT BE CONSIDERED TO BE A CONFLICT OF INTEREST
Q4~L. ESTATE -y G~Ty aF M-gMl Q ER GH
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~aJ~~O S<'C",~~~~~~ M- TP TO NOT (3Vy DR SEI,.L. 2E.gl..
~ n-s rvrm nas ~ pages - oe 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.
Employee Name Employee ID Number Employee signature & Date
1s;A~rrt~L g2.oc -c. 1 800 6 ~f G ~& `off
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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. .~ ~-y~~ -~H q y O N ~pp~Q,q~-E ~~,N..I,~ 2 pt= 2_
EMPLOYEE SIGNATURE DATE WITNESS SIGNATURE
EMPLOYEE NAME ID NUMBER
KA-n1 ~ L ~ . Seoo~s t8oo 6
II. TO BE COMPLETED BY EMPLOYEE'S CITY OF MIAMI BEACH DEPARTMENT
PLEASE CIRCLE ONE APPROVED SUPERVISOR SIGNATURE 8 DATE
NAME OF SUPERVISOR DISAPPROVED
PLEASE CIRCLE ONE APPROVED DIVISION HEAD SIGNATURE ~ DATE
NAME OF DIVISION HEAD DISAPPROVED
PLEASE CIRCLE ONE APPROVED DEPARTMENT HEAD SIGNATURE 8 DATE
NAME OF DEPARTMENT DIRECTOR DISAPPROVED
PLEASE CIRCLE ONE PPROVE CITY MANAGER SIGNATURE & DATE
CITY MANAGER
0 DISAPPROVED
This form has 2 pages - be sure to ~fnplete...bbth pages C,~
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