Betancourt, FrancoisC''' .
CITY OF MWMI BEACH ~`
REQUEST FOR APPROVAL OF OUTSIDE EMPLOYMENT ~. ,
Page 1 of 2 ~'
y
`~~ z,~
.--,
1. TO BE COMPLETED BY EMPLOYEE -This Form must be completed & approved_~pfior to
beginning any other employment ..
,,
e INCnouerinu ocr_eon~Nr^_ crrvncureur Rcecw rrufal FuP~ nwFNT
IDS DEPARTMENT/DIVISION
EMPLOYEE NAME: LAST NAME, FIRST NAME, MIDDLE NAME
'
s
~
13C~
~
~c ~ANCQ: A'i ~A.vens c
/~
j „rF i
WORK PHONES HOME PHONEri
Joe TITLE ~ -y>!.~ _
1",,?EFIGIa;riz L rc73 ~>!23 ;"s'Y-;~1-c~8.3O
WORK PHONE / EMPLOYEE'S OTHER PNONE 85 (BEEPER, CELL)
SUPERVISOR ,
~~N,ra //l~°NFiV ~~E I/lAc'ssuu .~fu -
r r3-T!Z>
78~ - y/1-:~~(r~
TO 8E CO~I.ETED BY: DO YOU AGREE WrtN THE
NORMAL WDRK DAYS AND TIMES NFORMATKIK N T16S SECTN711? YES NO
/J'1 °' TH ~ c?73a - i73cT~
B. INFORMATIAN RFRARI'fING AfJTSlOF FUPf nYUFNT
EMPLOYEE IDf! DEPARTMENT/DIVISION yp~,.~p Yy C1
LL1KL l!-
NAME OF BVSINESS OR INDIVIDUAL HIRING CMB EMPLOYEE ~
~
~~ ~~
C~ S, f`~,A clKC`Y.= ~
~ ,,
C"~',m~sr~~ro //,R r(2 i'A'U.' br?sE r~G
C /-
Y /"~3;~FS .J~::Zfvr3'/nAri
Joe TrcLE ~.lE(`u;,7 WORK PHONE r!
~~_ TYPE OF BUSINESS
g
~e7rr6Ar A('MS ~sre~+rcr; 12v'-t=lip ~iu rAlry
WORK PHONE i
SUPERVISOR ,,~~ //
~ SET /C[~`Frf hRArlAr. >(~~ -
72ti'-~7io
DATE OF HIRE
NO
RMAL WORK DAYS AND TIMES
y
1 FGfI'fKr,'lip /?'G'V /~N/ C~~~CCj
ADDRESS OF BUSINESS: STREET
CITY /'C."rSTrF~D STATE f ~- ZIP ~ o
DESCRIPTION OF DUTIES Cq4/ c'.vF~~r~re.ntr~T ~~'it i':7,ry f.:{TE /'lic~Pr rru'• ~ R•wn FI~(eAl7r+Qy a
r- Z
~~ m
~
~n
.-o _
C
u
WHAT DUTIES MIGHT BE CONSIDERED TO BE A CONFLICT OF INTEREST ~ t "J
107 Aw~ACF r,$` l4n; Y -n
~
f11
m
I
~ rns rorm nas z pages - de sure to compete both pages
_ _
CITY OF MIAMI BEACH
REQUEST FOR APPROVAL OF OUTSIDE EMPLOYMENT -CONTINUED
PAGE 2 of 2
c.
ey signing below, I certity 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 investigatlon 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 carding 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~~--pbyae Wama Employee ID Number Empbyae signat'ur`e a Date
fAFVV(cYS ~r*.ry(dct.`T fk.~~E'3 ~ 3.C.C'T~ i// ~?
D.
By signing below, I certify that I have rea this form comoletely and that l do not have any other emolovment. I understand
that fore I start any other empoyment, I must request and obtain the above aoorovals, 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 SKiNATURE ATE NESS SIOIIAT1NtE
EMPLOYEE NAME ID NUMt>EYt
II. TO BE COMPLETED BY EMPLOYEE'S CITY OF MU\Mt BEACH DEPARTMENT
PEASE CIRCLED PROVED S aIGNATUREa DATE
NAME OF SUPERVISOR DISAPPROVED
NAME OF DIVISION HEAD PLF~ISE GRCL E APP
DISAPPROVED I T d DATE
,I ,J ~/
NAME OF DEPARTMENT DIRECTOR PLEASE CIRCLE ON APPROV
DISAPPROVED DEPARTME SIGNA Ea DATE
~A,~oe~r-a.,~o ~,.--, ~~ S o-,
GTV MANAGER p~~
REASE CIRCLE ONE AP ~ OVED
DISAPPROVED GTV MANAGER SIGNATUREa D TE
RGc- m. ~dNZ 'cC--~ ~
r nrs roan nas ~ pages - ce sure to complete pom paps
:~~
M:LSCMBW UMARE50\Outside Employment Form 10 O6 03.dx REV: t0/06N3