Salas, Gladys Nelseyr'.
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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 & approved prior to
beginning any other employment
A. INFORMATION REGARDING CITY OFMlAM/ BFncH rcnnR~ Fnepr nvnrrFnrr
EMPLOYEE NAME: LAST NAME, FIRST NAME, MIDDLE NAME ID # DEPARTMENT /DIVISION
sQ las Gla d s N~ ~ (4388 &>>)c~in
Joe TITLE WORK PHONE # HOME PHONE #
Chi' ~4ccas5ibil~' c~or- 6888 C~ 22s- 19 87
SUP RVISOR WORK PRONE # EMPLOYEES OTHER PHONE #S (BEEPER, CELL)
runo ~or~ 6 266 ~ 786) 5e6 - 529 3
NORMAL WORK DAYS AND TIMES
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d TO BE COMPLETED BY SUPERVISOR: DO YOU AGREE WITH THE
INFORMATION IN THIS SECTIONZ YES NO
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B. INFORMATION REGARDING oUTSInF FMPI nvMFNr
NAME OF BUSINESS OR INDIVIDUAL HIRING CMB EMPLOYEE
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tYL52A rch d na EMPLOYEE ID #
N A DEPARTMENT /DIVISION
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~~ X93' ISoo TYPE OF BUSINESS
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SUPERVISOR
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P~ WORK PHONE #
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NORMAL WORK DAYSAND~~TI]M~E~S~(' DATE OF HIRE
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ADDRESS OF BUSINESS: STREET
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ITY MrdM ~~
STATE ~3~8~
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DESCRIPTION OF DUTIES
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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
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.
By signing below, I certify that I have read this form completely and that I do not have anv other employment. 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/$IGNATURE DATE WITNESS SIGNATURE
4YJ/ N o ~ » 08
EMPLOYEE NAME ID NUMBER
Glad) s ~• ~jas j~3g8
II. TO BE COMPLETED BY EMPLOYEE'S CITY OF MIAMI BEACH DEPARTMENT
~---- -
NAME OF SUPERVISOR PLEASE CIRCLE ONE
DISAPPROVED PROVED SUPERVISOR SIGNAT & ATE
~_. .
PLEASE CIRCLE ONE APPROVED DIVISION HEAD SIGN TUR & DATE
NAME OF DIVISION HEAD DISAPPROVED
PLEASE CIRCLE ON PPROVE DEPARTMENT HEAD SIG ATURE & DATE
NAME OF DEPARTMENT DIRECTOR DISAPPROVED
~~Ik~S ~~z f~c 2 %~ '/ ~~~ S
PLEASE CIRCLE ONE PR VED CITY MANAGER IG UR $ DA
CITY_IIAANAGER
~- _ DISAPPROVED ';. .~.
. __
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This form has 2 pages - be sure to complete both pages
M:1$CMB\HUMARES010utside Employment Form 10 06 03 doc REV: toros~os