Betancourt, FrancoisCITY 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 MIAMI BEACH (CM81 EMPLOYMENT
ID # DEPARTMENT /DIVISION
EMPLOYEE NAME: LAST NAME, FIRST NAME, MIDDLE NAME
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WORK PHONE # HOME PHONE #
JOB TITLE ~-'
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WORK PHONE # EMPLOYEES OTHER PHONE #S (BEEPER, CELL)
SUPERVISOR
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TO BE COMPLETED BY SlJPERVISOR: DO Y U AGREE WITH THE
NORMAL WORK DAYS AND TIMES INFORMATION IN THIS SECTION? YES NO
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B. INFORMATION REGARDING OUTSIDE EMPLOYMENT
EMPLOYEE ID # DEPARTMENT! DIVISION
NAME OF BUSINESS OR INDIVIDUAL HIRING CMB EMPLOYEE
WORK PHONE # TYPE OF BUSINESS
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WORK PHONE #
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NORMAL WORK DAYS AND TIMES DATE OF HIRE
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DESCRIPTION OF DUTIES -r~
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WHAT DUTIES MIGHT BE CONSIDERED TO BE A CONFLICT OF INTEREST
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Phis form has 2 pages - be sure to complete bo_.tJ pales ;~~ ~_
CITY OF MIAMI BEACH
REQUEST FOR APPROVAL OF OUTSIDE EMPLOYMENT -CONTINUED
PAGE 2 of 2
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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 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 8 Date
~A~v~o~s ~~AniC't~T J6S63 ~ ~ 7~3 ~y
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By signing below, I certify that I have read this form completely and that I do not have any other emDloyment. I understand
that before I start any other employment, I must reouest 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 SIGNRE DATE rr
~ WITNESS SIGNATURE
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EMPLOYEE NAME ID NUMBER
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tl. TO BE COMPLETED BY EMPLOYEE'S CITY OF MIAMI BEACH DEPARTMENT
PLEASE CIRCLE APPROVED S GAIATURE 8~ DATE
NAME OF SUPERVISOR DISAPPROVED
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PLEASE CIRCLE O APPRO IGNATU DATE
NAME OF DIVISION HEAD DISAPPROVED /
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PLEASE CIRCLE ON APPROV DEPARTMENT HEA (GNAT E 8~ DATE
NAME OF DEPARTMENT DIRECTOR DISAPPROVED
PLEASE CIRCLE O APPROVED CITY MANAGER SIGNATU E 8 DATE
CITY MANAGER DISAPPROVE
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This form has 2 pages - be sure t~orrjtp~te b`ofF-i ages
M:1$CMB\HUMARES010utside Employment Form 10 O6 03.doc REV: 10/06/03