Rolle, Paulette KCITY 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 OFMtAMI BEACH /CMB) EMPLOYMENT
ID # DEPARTMENT / DNISION
EMPLOYEE NAME: LAST NAME, FIRST NAME, MIDDLE NAME
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WORK PHONE # HOME PHONE #
JOB TITLE
WORK PHONE # EMPLOYEES OTHER PHONE #S (BEEPER, CELL)
SUPERVISOR
NORMAL WORK DAYS AND TIMES TO BE COMPLETED BY SUPERVSOR: DO OU AGREE WITH THE
INFORMATION IN THIS SECTION? YES NO
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B. INFORMATION REGARDING OUTSIDE EMPLOYMENT
EMPLOYEE ID # DEPARTMENT / DNISION •
NAME OF BUSINESS OR INDIVIDUAL HIRING CM8 EMPLOYEE
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WORK PHONE # TYPE of BUSINESS .~pEC/ r9L ~Y E] MANUFA
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WORK PHONE #
SUPERVISOR
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DATE OF HIRE
NORMAL WORK DAYS AND TIIyIES
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DESCRIPTION OF DUTIES ~
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WHAT DUTIES MIGHT BE CONSIDERED TO BE A CONFLICT OF INTEREST C/) A
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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.
8y 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.
EM YEE SIGNATURE DATE WITNESS S NATURE
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EMPLOYEE NAME ID NUMBER
II. TO BE COMPLETED BY EMPLOYEE'S CITY OF MIAMI BEACH DEPARTMENT
PLEASE CIRCLE ONE APPROVED SUPERVISOR SIGNATURE & DATE
NAME OF SUPERVISOR DISAPPROVED
PLEASE cIRCL>=ONE APPROVED DNISION HEAD SIGNATURE S~ DATE
NAME OF DNISION HEAD DISAPPROVED
PLEASE CIRCLE ONE PROVED EPA TMENT SIGNATURE $~ DATE
NAME OF DEPARTMENT DIRECTOR DISAPPROVED
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PLEASE CIRCLE ON APPROV D CITY MANAGER SIGNATURE $~ ATE
CITY MANAGER DISAPPROVED
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This form has 2 pages - be sure to gc~mpl~teJboth pa~es~ ~
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M:1$CMBIHUMARESOtOutside Employment Form 10 06 03.doc REV: taosro3
By signing below, I certify that I have read this form completely arid that I do not have any other employment. I understand
that before I start any other employment, 1 must request and obtain the above approvals, t further understand that failure to
cgmply with Outside Employment procedures could lead to disciplinary action up to and including termination of my
employment with the City Qf Miami Beach.