Rolle, Paulette K (2)CITY OF MIAMI BEACH
REQUEST FOR APPROVAL OF OUTSIDE EMPLOYMENT
Page 1 of 2
I. TO BE COMPLETED BY EMPLOYEE -This Form must be completed 8~ approved prior to
beginning any other employment
INFORMATION REGARDING CITY OF MIAMI BEACH CMB EMPLOYMENT
BR O IE~ AME: LAST (~ ~ ST NAME, MIDDLE NAME ID #
~ ~ ~ , ! ~ DEPARTMENT / OMSION
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WORK PHONE # HOME PHONE #
J08 TITLE ~ +~ ~ ` n~ ~~ ~ ~~~~
WORK PHONE # EMPLOYEE'S OTHER PHONE #3 (BEEPER, CELL)
SUPERVISOR
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NORMAL WORK DAYS AND TIMES TO BE COMPLETED 8Y SUP~SOR: DO Y~tl AGREE WITH THE
INFORMATION IN THIS SECTION? ~/ YES NO
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B_ INFORMATION REGARDING OUTSIDE EMPLOYMENT
NAME O>= BUSINESS OR INDIVIDUAL HIRING CMB EMPLOYEE .FJAW.GYiiEID#
f„~CCNSF DEPARTMENT/DIVISION
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WORK PHONE # TYPE OF BUSINESS
Joe TITLE
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WORK PHONE #
SUPERVISOR
DATE OF HIRE
NORMAL WORK DAYS AND TIMES
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ADDRESS OF BUSINESS: ST//RES~ET Q n
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CITY / STATE L ZIP 3 3 /,Z~'
DESCRIPTION OF DUTIES
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WHAT DUTIES MIGHT BE CONSIDERED TO SE A CONFLICT OF INTEREST ~
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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.
fay signing below, I certify that all of the information given en 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.
Employes Name Employee ID Number E yee signatur D to
D.
By signing below, I certify that I have read this form comDletel}~and that t do not have anv other employment. I understand
that before I start any other employment, !must request and obtain the above aaarovals. 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.
II. TO BE COMPLETED BY EMPLOYEE'S CITY OF MIAMI BEACH DEPARTMENT
PLEASE CIRCLE ONE APPROVED SUPERVISOR SIGNATURE & DATE
NAME OF SUPERVISOR DISAPPROVED
PLEASE CIRCLE ONE APPROVED DIVISION HEAD SIGNATURE & DATE
NAME OF DNISION HEAD DISAPPROVED
1
PLEASE CIRCLE ONE PROVED ENT HE SIG TORE 8 DATE
NAME OF DEPARTMENT DIRECTOR DISAPPROVED ~ /'
tR.O AM.~ a .--~ x
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PLEASE CIRCLE ON APPROVE CITY MANAGER SIGNATURE E~ DATE
CITY MANAGER DISAPPROVE
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" This form has 2 pages - be sure to co ple~fe b~pth page`s ~,.~..J
M:1$CMBIHUMARES010utside Employment Form t0 06 03.doc ~J REV: tio/oe/o3
EMPLOYEE NAME ID NUMBER