Brown, Angela
CITY OF MIAMI BEACH
REQUEST FOR APPROVAL OF OUTSIDE EM
Page 1 of 2
I. TO BE COMPLETED BY EMPLOYEE -This Form must be completed & approved prior to
beginning any other employment
O INFORMATION RFGCRDING CITY OF MIAMI BEACH /CM61 EMPLOYMENT
ID# DEPARTMENT/DIVISION
E LOYEE NAME: LAST NAME, FIRST NAME, MIDDLE NAME
~~
WORK PHONE # HOME PHONE #
Jos TITLE
WORK PHONE # MPLOYEE~S HER PHONE #5 (BEEPER, CELL)
SUPERVISOR
~',[(
!JW ~ .
TO BE COMPLE ED BY SUPERVISOR: DO Vq GREE WITH THE
NORMAL WORK DAYS AND TIMES ' I RMATION IN THIS SECTIONS J~ YES NO
R. INFORMATION RF(;AROING OUTSIDE FMPI OYMFNT
EMPLOYEE D# DEPART MENT/DIVISION
NAME OF BUSINESS OR INDIVIDUAL HIRING CMB EMPLOYEE
WORK PHONE# TYPE OF BUSINESS
JOB TITLE
WORK PHONE #
SUPERVISOR
~/-~ /'~
~~' ~-l./ " I I ^~
~ ~ 7
~ '
ATE OF HIRE
NORMAL WORK DAYS AND TIMES
~ - F ~,
ADDRESS OF BUSINESS: S'f REET
I 1 ~ ~~CITY STATE ZIP ~
DESCRIPTION OF DUTIES
1~
~ C~e
-,~r« ~ ~ A~
~
~~ ~
`~ ~
WHAT DUTIES MIGHT BE CONSIDERED TO BE A CONFLICT OF INTEREST
- •nii
...i:
i<Ci ~~P~^ n, e;
This form has 2 pages - be sure to com'~lete both pages
,_ '
CITY OF MIAMI BEACH
REQUEST FOR APPROVAL OF OUTSIDE EMPLOYMENT -CONTINUED
PAGE2of2
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.
EMPLOY $IG T DATE WIT IGNAT RE
AA
EMP YEE NAME ID NUM~BER
II. TO BE COMPLETED BY EMPLOYEE'S CITY OF MIAMI BEACH DEPARTMENT
PLEASE CIRCLE ON PPROVED 3 SUPERVISOR SIGNATURE & DATE
NAME OF SUPERVI R , M~
ti
' DISAPPROVED .__~~
L ~ 7
j
• Sy l
la Z ~
-1 PLEASE CIRCLE ONE PPROVED DI 10 AD SIGNATURE & DATE
~
NAME OF DIVI NHE D 711 ^t
VI V Ln DISAPPROVED .Y
1 4
if(/ L/
PLEASE CIRCLE ON PROVED D AR EN HEAD SIGNATURE 8 DA
i~
NT ~
NAME
P ~ c R DISAPPROVED
~
`
/ `
/ 'y
~
.~ V
PLEASE CIRCLE ONE PROVED CITY MANAGER SIGNATURE & DATE
aTV MANAGER DISAPPROVED
'\.-= . 1y
This form has 2 pages - be sure to complete both pages i , / )
J ~.~'
M:4$CM8\HUMARESO10utsitle Employment Form 70 O6 03.doc REV: 10/Ofi/D3
By signing below, I certify that I have read this form completely and that I do not have anv other emDlovment. I understand
that before I start any other employment, 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.