Cardeno, Hernanf
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CITY OF MIAMI BEACH
REQUEST FOR APPROVAL OF OUTSIDE EMPLOYMENT
Page 1 of 2
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~,~ TD BE COMPLETED BY EMPLOYEE -This Form must be completed & approved prior to
keginnil~g ~n~ other employment
~_ INFORMATION REGARDING CITY OF M1AMl BEACH (CMB1 EMPLOYMENT
ID # DEPARTMENT 1 DIVISION
`EMPLOYEE NAME: LAST NAME, FIRST NAME, MIDDLE NAME
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WORK PHONE # HOME PHONE #
.108 TITLE
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WORK PHONE # EMPLOYEE'S OTHER PHONE #S (BEEPER, CELL)
'SUPERVISOR
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TO BE COMPLETED BY SUPERVISOR: DO YOU AGREE WITH THE
NORMAL WOR~Q DAYS AND TIMES
M n~ . - ~f'~ i. 9~M - S'~~ INFORMATION IN THIS SECTION? ~ YES NO
~_ INFORMATION REGARDING OUTSInF F_MPI OYMFNT
EMPLOYEE ID # DEPARTMENT (DIVISION
',NAME OF BUSIKfSS OR INDIVIDUAL HIRING CMB EMPLOYEE
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Joe TITLE
/~~~J~~'~'ru~`~'T' D~1su~T~~~' WORK PHONE # ~
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~ WORK PHONE #
SUPERVISOR
DATE OF HIRE
'NORMAL WORK DAYS AND TIMES
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}ADDRESS OF BlJSiMESS: STREET
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CITY STATE ZIP
DESCRIPTION OF DUTIES
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1lUHAT DUTIES MIGHT BE CONSIDERED TO BE A CONFLICT OF INTEREST
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I nls torm nas 1 pages - ae sire to compete both pages
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CITY OF MIAMI BEACH
REQUEST FOR APPROVAL OF OUTSIDE EMPLOYMENT -CONTINUED
PAGE2of2
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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 suffiaent 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,
espec~aily 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.
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Employee Name Employee ID Number ~ E loyignature & ate q
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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
emplo~rment with the City Of Miami Beach.
LOYE NATURE DATE WITNESS SIGNATURE
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EMPLOYEE NAME ID NUMBER
II. TO BE COMPLETED BY EMPLOYEE'S CITY OF MIAMI BED D~ARTMENT
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PLEASE CIRCLE ON APPRO D S ERVIS GNATURE & DATE
NAME OF SUPERVISOR DISAPPROVED
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PLEASE CIRCLE ON PROV DI SI AO SIGNATURE & DATE
NAME OF DIVISION HEAD DISAPPROVE
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PLEASE CIRCLE ON APPROVED ~ D PARTMENT HEAD SIGNATURE & DATE
NAME OF DEPARTMENT DIRECTOR DISAPPROVED ~"`
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PLEASE CIRCLE ONE PP OVED CITY MANAGER SIGNATU & DATE
CITY :MANAGER DISAPPROVED
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I nis Corm has zpages - be sure to c~plec~~bth pages R~
M:I~CMBIHUMARESOIOutside Employment Form 10 06 03.doc REV: 10106103