Rodriguez, EnidCITY 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 M/AM/BEACH CM,
EMPLOYEE NAME: LAST NAME, FIRST NAME, MIDDLE NAME ID #
JOB TITLE WORK PHONE #
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SUPERVISOR WORK PHONE #
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NORMAL WORK DAYS AND TIMES
B. INFORMATION REGARDING OUTSIDE EMPLOYMENT
NAME OF BUSINESS OR INDIVIDUAL HIRING CMB EMPLOYEE EMPLOYEE ID #
JOB TITLE WORK PHONE #
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SUPERVISOR WORK PHONE #
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NORMAL WORK DAYS AND TIMES I~.IeQ(~~~ ~/V~[ DATE OF HIRE
ADDRESS OF BUSINESS: STREET
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DESCRIPTION OF DUTIES
EMPLOYMENT
DEPARTMENT /DIVISION
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HOME PHONE #
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EMPLOYEE'S OTHER PHONE #S (BEEPER- CFi
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TO BE COMPLETED BY SUPERVISOR: DO YOU AGREE WITH THE
INFORMATION IN THIS SECTION? - ~~ YES NO
DEPARTMENT /DIVISION
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TYPE OF BUSINESS
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WHAT DUTIES MIGHT BE CONSIDERED TO BE A CONFLICT 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. 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
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.
EMPLOYEE SIGNATURE DATE WITNE SIGNATURE
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EMPLOYEE NAME ID NUMBER
II. TO BE COMPLETED BY EMPLOYEE'S CITY OF MIAMI BEACH DEPARTMENT
NAME OF SUPERVISOR PLEASE CIRCLE ONE PPROVE
DISAPPROVED SUPERVISOR SIGNATURE & DATE
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PLEASE CIRCLE Ory~ ROVED 1 DI SIO SIG TURE S~ DATE
NAME OF DIyISION •~EAD DISAPPROVE`-°
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PLEASE CIRC ONE APPRO DE ART AD I NA RE 8~ DATE
NAME OF DEPAR MENT DIRECTOR DISAPPRO
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PLEASE CIRCLE ONE APPROVED CI ANAGER SIGNATURE & DATE
CITY MANAGER DISAPPROVED
This form has 2 pages - be sure to complete both pages
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