Almagro-Johnson, Olivia~?~'~I~l
2001 JtlL i 9 PM 3~ 48 : ~~ ~ ~; r~ v o
CITY OF MIAMI BEACH
~{T`~ ~ `t_~ -~,`S GRId62UEST 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
A. INFORMATION REGARDING CITY OF MIAMI BEACH (CMBI EMPLOYMENT
ID # DEPARTMENT /DIVISION
MPLOYEE NAME: LAST NAME, FIRST NAME, MIDDLE NAME.
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WORK PHONE # HOME PHONE #
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WORK PHONE # EMPLOYEE'S OTHER PHONE #S (BEEPER, CELL)
SUPERVISOR
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NORMAL WORK DAYS AND TIMES TO BE COMPLETED BY SUPERVISOR: DO YOU AGREE WITH THE
INFORMATION IN THIS SECTION? / YES NO
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B_.__ INFORR!IATION REGARDING OUTSIDEEMP__LOYMENT _
NAME OF BUSINESS OR INDIVI UAL HIRING CMB EMPLOYEE
EMPLOYEE ID# __
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.106, ITL - WORK PHONE # TYPE Ur auJiNtSS
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SUPERVISOR _ WORK PHONE # _
NOR L W RK DAYS AND TIMES DATE OF HIRE
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ADDRESS OF BUSINEFIS: STREET
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STATE ~L-- /'
ZIP ~~ ~~~ - ~ ~ 1~~
DESCRIPTION OF DUTIES
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WHAT DUTIES MIGHT BE CONSIDERED TO BE A CONFLICT OF INTEREST
I nls torm nas 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.
e Name Employee ID Number _
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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 ~~de Employment procedures could lead to disciplinary action up to and including termination of my
emplovml~{with the Citu--Of Miami Beach.
IYEE NAME
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DATE N SS SIGNA
ID NUMBER
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II. TO BE COMPLETED BY EMPLOYEE'S CITY OF MIAMI BEACH DEPAI~,TMEfj{,T
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PLEASE CIRCLE ON PPROVED UPERVISO GNATUR DA
NAME OF SUPERVISOR DISAPPROVED 1_
PLEASE CIRCLE ONE APPROVED DIVI N HEAD SIGNATURE & DATE
NAME OF DIVISION HEAD DISAPPROVED
PLEASE CIRCLE O APPROVED ME T EAD IGNATU DAT
NAME OF DEPARTMENT DIRECTOR DISAPPROVED ~'1
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PLEASE CIRCLE ONE P OVE Y MA ER SIGNATURE 8 DATE
CITY MANAGER DISAPPROVED
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phis form has 2 pages - be sure to ete bo
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