Martinez, Juanl~.F~'Fi~F~}
CITY OF _;9111AM1 BEACH Z~~~ .1 ~~, ~ 2 Q~ ~ ~ ; ~ Q
REQUEST FOR APPROVAL OF OUTSIDE EMeLOYMENT
Page 1 of 2 ~l s`1` ~Ll;~;';; ~r;-1C~
I. TO BE COMPLETED BY EMPLOYEE -This Form must be completed & approved prior to
beginning any other employment
A. INFORMATION REGARDING CITY nF MIAMI RFdCH /CMRI FMP/ nYMFNT
EMPLOYEE NAME: LAST NAME, FIRST NAME, MIDDLE NAME
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JOB TITLE WORK PHONE
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SUPERVISOR WQRK PHOIyE #
(~~ `7 ) EMPLOYEE'S OTHER PHONE #S (BEEPER, CELL)
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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
B_ INFnRMATInN RF(;ARnINr nUTSII~F FMPI t7YMFNT
NAME OF BUSINESS OR INDIVIDUAL HIRING CMB EMPLOYEE
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JOB TITLE ~ } , ~" WORK PHONE #
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NORMAL WORK DAYS AND TIMES ,^
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ADDRESS OF BUSINESS: STREET
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DESCRIPTION OF DUTIES f ~ "~
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WHAT DUTIES MIGHT BE CONSIDERED TO BE A CONFLICT OF INTE REST
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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
Juav~ C- ar27+ neZ Employee ID Number
~ C ~~ Employee signet re Date
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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 emplovment. 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 WITNESS SIGNATURE
EMPLOYEE NAME ID NUMBER
II. TO BE COMPLETED BY EMPLOYEE'S CITY OF MIAMI BEACH DEPARTMENT
PLEASE CIRCLE ONE APPROVED SUPERVISOR SIGNATURE S~ DATE
NAME OF SUPERVISOR DISAPPROVED
_. _ _._.
PLEASE CIRCLE Ne APPROVED _ Dlvlsl HEAD SIGNATURE & DATE
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NAME OF DIVISION HEAD DISAPPROVED - --~ t I'
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PLEASE CIRCLE ONE i~ DEPARTMENT HEAD SIGNATURE & DATE
NAME OF DEPARTMENT DIRECTOR DISAPPROVED --''
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PLEASE CIRCLE OPIE APPROVED CITY MANAGER SIGNATURE & DA
CITY MANAGE
R DISAPPROVED
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This form has 2 pages - be sure to cbmplet both pages --'
M:\$CMB\HUMARESO10utside Employment Form 10 O6 03.doc REV: 10/06/03