Hasburn, JorgeCITY OF MIAMI BEACH
REQUEST FOR APPROVAL OF OUTSIDE EMPLOYMENT ~'° ~~ ° ~~ ~ ~' ~. , ~. ~ ;~' ;
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i, TO BE COMPLETED BY EMPLOYEE -This Form must be completed & approved prior to
beginning any other employment ~ ~. - 2 s - o ~~ F ~ , . ~ ; ~ ~ v o
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EMPLO EE NAME: LAST NAME, FIRST NAME, MIDDLE NAME
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DEPARTMENT /DIVISION
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WORK PHONE # HOME PHONE #
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W012K PHONE # EMPLOYEE'S OTHER PHONE #S (B R, LL
SUPERVISOR ~ ~ ~i~
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' TO BE GbAIPLETEb BY SUPEIMdOR: DO YOU ARiREE MNTH THE
WORK DAYS ANO TIMES
NORMA
L WPORMATION W TNIS SECTION? YES ~,_ NO
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EMPLOYEE ID #
DEPARTMENT /DIVISION
NAME BUSINESS OR INDIVIDUAL HIRING CMB EMPLOYEE
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WOFtK~HONE #
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WORK PHONE #
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NORMAL WORK DAYS A
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ADDRESS OF BUSINESS: STREET
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DESCRIPTION OF DUTIES T2~~~~ , ~' -•~~ ~~~~~T ~ ~
WHAT DUTIES MIGHT BE CONSIDERED TO BE ACONFLICT OF INTEREST
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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, t 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,
espeaaBy if there arises any possible conflict of interest. Failure to do so may lead to disciplinary action, including termination
of emplovment with the City of Miami Beach. This request for approval will be made on a yearly basis.
~,r,~,lpyee Name Empbyee ID Number Empbyee signature ~ /~ i
p E' ~~~~ n ~ /~C o~ 111
D.
BY signing below, I certify that I have read this form completely and that 1 do not have anv other employment. 1 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
mployment with the City O Miami Beach.
Mr~.orse StoNN DATE f Gi ~''I NESS SlowaruRE
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Er~[.oYee Na>~ ID NuMS~e
11. TO BE COMPLETED BY EMPLOYEE'S CITY OF MIAMI BEACH DEPARTMENT
PLEASE CIRCLE APPROVED SUPERVISOR SIGNATURE 8 DATE
NAME of SuPERwsoR DISAPPROVE ~ ~ ~ ~~
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PLEASE CIRCLE ONE APPROVED DIVISIQN HEAD SIGNATURE & DATE
NAME OF DMSION HEAD DISAPPROVED
' 04 13 0~-
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PLEASE CIRCLE ONE PROVED T H TURE 8 DATE
NAME OF DEPARTMENT DIRECTOR
,- DISAPPROVED
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Y MANAGER
C PLEASE CIRCLE ONE A PRO
D CITY MANAGER SIGNATUR DATE
~~
IT DISAPPROVE ~ iy0
This form has Zpages - be sure to co~p~ete qo;n pages
M:~CMBW UMARESO~Outside Empbyment Form 10 06 03.doc REV- ~~~