Prieto, Rosendo E.CITY OF MIAMI BEACH ~,
REQUEST FOR APPROVAL OF OUTSIDE EMPLOYMENT ~:
Page 1 of 2 -~- ~'`
I. TO BE COMPLETED BY EMPLOYEE -
beginning any other employment
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This Form must be completed & approved prior to
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A. INFORMATION RFC~ARnINC~ rrrvnFnn~nw-rRFerNi~^nnai ~nec, nv~u-c~~-r ~ `'~~
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NORMAL WORK DAYS AND TIMES TO BE COMPLETED BYSUPERVISOR: DO AGREE WITH THE
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B. INFORI'AATION REGARDING ntlrSmF Fnnpi nvnnFNr
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DESCRIPTION OF DUTIES
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WHAT DUTIES PJIIGHT BE CONSIDERED TO BE A CONFLICT OF INTEREST
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i nis rorm nas 1 pages - be sure to complete both pages
CITY OF MIAMI BEACH
REQUEST FOR APPROVAL OF OUTSIDE EMPLOYMENT -CONTINUED
PAGE 2 of 2
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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.
Employee Name Employee ID Numher ,~J_, Employee signature
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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 SIGNATURE DATE WITNESS SIGNATURE
EMPLOYEE NAME ID NUMBER
II. TO BE COMPLETED BY EMPLOYEE'S CITY OF MIAMI BEACH DEPARTMENT
PLEASE CIRCLE O APPROVE PERwsoR SIGNATURE ~ DATE
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~ DISAPPROVED ~
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NnAME OF DIVISION H(~EJ~AD ~
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DISAPPROVED APPROVED DIVISION HEAD SIGNATURE B~ DATE
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NAME OF DEPARTM IRECTOR PLEASE CIRCLE ON
DISAPPROVED PPROVED DEPARTMENT HEAD $IGNATU & DATE ~//O
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CITY MANAGER PLEASE CIRCLE ONE PROVED CITY MANAGER SIGNATURE ~ DATE
DISAPPROVED ~_x N'ID1
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This form has 2 pages - be sure to cor~hplete bQt pages
M:1~CMBIHUMARES010utside Employment Form 10 06 03.doc REV: 10/06/03