DeFreze, Carolinea
CITY OF MIAMI BEACH zo~~
REQUEST FOR APPROVAL OF OUTSIDE EMPLOY ~ ~ ~ PM ~2: 20
Page 1 or'2 CITY C~~N~.S C~F~CI_
I. TO BE COMPLETED BY EMPLOYEE -This Form must be completed & approved prior to
beginning any other employment
A• INFORMATION REGARDING CITY OF MIAMI BEACH /CM61 FMP/ AYMENT
EMPLOYEE NAME: LAST NAME, FIRST NAME, MIDDLE NAME ID #
Q DEPARTMENT /DIVISION
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WORK PHONE # HOME PHONE #
JOB TITLE .. ,
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~ WORK PHONE # EMPLOYEE'S OTHER PHONE #S (BEEPER, CELL)
SUPERVISOR
TO BE COMPLETED BY SUPERVISOR: DO YOU AGREE WITH THE
R~K DAYS AND TIMES _
NOQR~MAL WO
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~ INFORMATION IN THIS SECTION? YES NO
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B. INFORMATION REGARDING OUTSIDE EMPLOYMENT
NAME OF BUSINESS OR INDI
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CMB EMPLOYEE EMPLOYEE ID # DEPARTMENT /DIVISION
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JOB TITLE~'~-C~\ ~-~~ M~,~-'M~ ,2~ ~ HONE # TYPE OF BUSINESS
SUPERVISOR WORK PHONE #
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NORMAL WORK DAYS AND TIMES \ DATE OF HIRE
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ADDRESS OF BUSINESS: STREET ~`
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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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I nls corm nas 1 pages - pe sure to complete both pages
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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.
Employee Name _ Employee ID Number Employee signature & Date
D.
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 ONE APPROVED SUPERVISOR SIGNATURE & DATE
NAME OF SUPERVISOR DISAPPROVED
PLEASE CIRCLE ON APPROVED DIV T RE 8 DATE
NAME OF DIVISION HEAD DISAPPROVED
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PLEASE CIRCLE ONE :APPROVED~~`, DEPARTM NTH SIGN URE 8~ DATE
NAME OF DEPARTMENT DIRECTOR DISAPPROVED` ,.~.
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PLEASE CIRCLE ON P ROV CI ANAGEF~SIGNA URE & DATE
CITY MANAGER DISAPPROVED 5~
This form has 2 pages - be sure to c~fnpl to 0th ~~s--~
M:\$CMB\HUMARESO\Outside Employment Form 10 06 03.doc REV: 10/06103