Brooks, Kathie, Gene Form 2~ H ~t Z ~F Z
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 (CMBI EMPLOYMENT
ID # DEPARTMENT /DIVISION
EMPLOYEE NAME: LAST NAME, FIRST NAME, MIDDLE NAME
$2oo>rs Is;ArHIE LTC-.~G \g od6 ova G~"r ~ ~Q~N~a-.k~ IKP~D
WORK PHONE # HOME PHONE #
JOB TITLE
111 ~E.GT"O ~
s-6'~3 ~d
3os - X67 - ~ 8 7-~
WORK PHONE # EMPLOYEE'S OTHER PHONE #S (BEEPER, CELL)
SUPERVISOR
So2GL C-,~o+JZAt~-~E.Z
3C5-6'j31o~
3or- 3~~-576
TO BE COMPLETED BY SUPERWSOR: DO YOU AGREE WITH THE
NORMAL WORK DAYS AND TIMES INFORMATION IN THIS SECTION? YES NO
B. INFORMATION REGARDING OUTS/DEEMPLOYMENT
EMPLOYEE ID # DEPARTMENT! DIVISION
NAME OF BUSINESS OR INDIVIDUAL HIRING CMB EMPLOYEE
$a SH o2.E. ~~s~ oNS 4 e~oP _._-
WORK PHONE # TYPE OF BUSINESS
JOB TITLE
P2{~~ DE.-J~' T~asV2E.2 .3~5.3~1 ~& p+R~~2Ty MA~JgCT~rv16 ~ s
WORK PHONE #
SUPERVISOR
~~
DATE OF HIRE
NORMAL WORK DAYS AND TIMES
H ov2.s vJ K. Rs ~~D ago i
ADDRESS OF BUSINESS: STREET
~p03 1 LA C~f~-+~CITY M -AN- ..v. .'r" STATE , ` ZIP 33~~-~
DESCRIPTION OF DUTIES
p~C,G~V V~1T•t N CT ~Q pPEQ,T y M A~J A CT~Mb~I t
WHAT DUTIES MIGHT BE CONSIDERED TO BE A CONFLICT OF INTEREST
This form has 2 pages - be sure to complete both pages
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 si natu e 8 Date
D.
By signing below, I certify that I have read this form completely and that I do not have anv other emDloyme~ 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. CX GEPT A S sNOv~ N OF ~PA2AZE 1=rXLly 1oF ~
EMPLOYEE SIG R DATE WITNESS SIGNATURE
~ c
~a
EMPLOYEE NAME ID NUMBER
K~Trt I E G ~ 82oacS tBooF,
II. TO BE COMPLETED BY EMPLOYEE'S CITY OF MIAMI BEACH DEPARTMENT
PLEASE CIRCLE ONE APPROVED SUPERVISOR SIGNATURE S~ DATE
NAME OF SUPERVISOR DISAPPROVED
PLEASE CIRCLE ONE APPROVED DIVISION HEAD SIGNATURE S~ DATE
NAME OF DIVISION HEAD DISAPPROVED
PLEASE CIRCLE ONE APPROVED DEPARTMENT HEAD SIGNATURE S~ DATE
NAME OF DEPARTMENT DIRECTOR DISAPPROVED
PLEASE CIRCLE ONE PP O E CITY MANAGER SIGNATURE 8 DATE
CITY MANAGER DISAPPROVED
J This form has 2 pages - be sure t~`omp~Js~le both pag~s.~~
M:\$CMBIHUMARESO\Outside Employment Form 10 06 03.doc REV: 10/06/03