Barreiro, George L.CITY OF MIAMI BEACH
REQUEST FOR APPROVAL OF OUTSIDE EMPLOYMENT
Page 1 of 2
1. TO BE COMPLETED BY E~IAPLOYEE -This Form must be completed 8~ approved prior to
beginning any other employment
A. INFORMATION REGARDING CITY OF MIAM/ BEACH (CMB) EMPLOYMENT ~ c
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ID # DEPARTMENT / DIVISION ~ ""'~
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EMPLOYEE NAME: LAST NAME, FIRST NAME, MIDDLE NAME
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JOBTRLE V~~~~ NE#
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WORK PHONE # EMPLOYEES OTHER PHONE #S (BEEPER, CELL) 'TS
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.SUPERVISOR
NORMAL WORK DAYS AND TIMES TO BE COMPLETED BY: DO Y AGREE WITH THE
INFORMATION W THIS SECTKM~IZ ~~YES
NO
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B. INFORMATION REGARDING OUTSIDE EMPLOYMENT
EMPLOYEE ID # DEPARTMENT /DIVISION
NAME OF BUSINESS OR INDIVIDUAL HIRING CM8 EMPLOYEE
JOB TfTLE ~ORK PHONE #
~ TYPE OF BUSINESS
V1bRK PHONE#
SUPERVISOR
NO
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MAL WORK DAYSy~AND TI~M~.~Syiy/ ,/ ~ / DATE OF HIRE __
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DRESS OF BUSIN :STREET s~ C !-~"?
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CITY
STATE ZIP U i
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DESCRIPTIDN OF DUTIES _ // /1 ~ // ~ r' ~ ~ ~ t ~. "'
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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 Employ ID umber Employee sig
D.
By signing below, 1 certify that I have read this form completely and that I do not have any other emplovment. I understand
that fore 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.
~~
SKiWATURE
EMPLOYEE NAME ID ~s~L~
II. TO BE COMPLETED BY EMPLOYEE'S CITY OF MIAMI BEACH DEPARTMENT
~~
dy~ //0 __ / PLEASE CIRCLE ON SUPERVISOR SIGNATURE 8 DATE
~
AME OF SUPERwcnR DISAPPROVED
3
PLEASE CIRCLE N H SIGNAT RE & DAT
NAME OF DIVISION HEAD DISAPPROVED
~ 7 Z3
PLEASE CIRCLE ONE PROD- EPARTMENT H IGNATU & DATE
NAME OF DEPARTMENT DIRECTOR DISAPPROVED
I'
~, .
PLEASE CIRCLE ONE PPROVE CI AN IGN UREBDAT~
CIrY M AGER DISAPPROVED
This form has 2 pages - be sure to c~mp-ete~` ~~b~~ages
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~7
M:1$CMBIHUMARES010utside Employment Form 10 06 03.doc REV: 10/D6J03