Muñoz, BeatrizPM 3~ 59
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CITY OF MIAMI BEACH -
2008 f EB ~'~ =~ -~
CITY ~,~~~~.~ 0~~ f(~EQUEST FOR APPROVAL OF OUTSIDE EMPLOYMENT =-~ ~: :~-
Page 1 of 2 tr2/,2+ (~~:~ ~' _ , „
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I. TO BE COMPLETED BY EMPLOYEE -This Form must be completed 8 approved Dior tt
beginning any other employment
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A_ INFORMATION REGARDING CITY OF M/dMl RFdCH /CMRI FMPI nVMFNT
ID # DEPARTMENT /DIVISION
EMPLOYEE NAME: LAST NAME, FIRST NAME, MIDDLE NAME _
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WORK PHONE # HOME PHONE #
JOB TITLE ~ )~,
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WORK PHONE # EMPLOYEE'S OTHER PHONE #S (BEEPER, CELL)
SUPERVISOR ~ 7~(?5
M ~ ~ (,~ ~ F C cnr ~ ~ ,,, 5' ci ~, p .M) TO BE COMPLETED BY SUPERVISOR: DO YOU AGREE WITH THE
NORMAL WORK DAYS AND TIMES
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:Cd 2 ~`A ~ ) INFORMATION IN THIS SECTION? YES NO
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B. INFORMATION REGARDING OUTSIDE EMPLOYMENT
EMPLOYEE ID # DEPARTMENT /DIVISION
NAME OF BUSINESS OR INDIVIDUAL HIRING CMB EMPLOYEE
JOB TITLE ~NORK PHONE #
~~S TYPE OF BUSINESS
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WORK PHONE #
SUPERVISOR
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cL DATE OF HIRE
NORMAL WORK DAYS AND TIMES f
ADDRESS OF BUSINESS: STREET ~ ~ ~ lY *'%
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CITY STATE ZIP
DESCRIPTION OF DUTIES ~ `~ ~` 9v .< .J_. ~-\ cyC; ~L-.> ~ r~ C. ~ 11?~G'l
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WHAT DUTIES MIGHT BE CONSIDERED TO BE A CONFLICT OF INTEREST
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CITY OF MIAMI BEACH
REQUEST FOR APPROVAL OF OUTSIDE EMPLOYMENT -CONTINUED
PAGE 2 of 2 ( [y12a1~ ~)~
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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.
Em loyee Name Employee ID Number si natured Date_ ~ Z /~~ ~
D.
By signing below, I certify that I have read this form completely and that I do not have anv 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 SI ATU~ DATE ~ WITS ESS IGNAE RE
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EMPLOYEE NAME ID NUMBER
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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 NE AP OVE DIVISI EA SIGNATURE & DAT
N F DIVISION HEAD DISAPPROV
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PLEASE CIRCLE ON ROVED DEPARTM T HEAD SIGNAT E 8~ ATE
NAME OF DEPARTMENT DIRECTOR DISAPPROVED
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PLEASE CIRCLE ONE OVED CITY MANAGER SI TUBE S. ATE
CITY MANAGER DISAPPROVED _
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M 1$CMB\HUMARESO~Outside Employment Form 1D D6 03.doc REV ioio6/03