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CITY OF MIAMI BEACH ~ a
REQUEST FOR APPROVAL OF OUTSIDE EMPLOYMENT ~ ~
Page 1 of 2 ~. '~
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I. TO BE COMPLETED BY EMPLOYEE -This Form must be completed & approved per to{a,
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beginning any other employment ~~ ~? ~.`
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A INFnRMATI(~N RFC,ARnING CITY ~F MIAMI F3FACH /CMB1 EMPLOYMENT
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)
SUPERVI R /"
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TO BE COMPLETED BY SUPERVISOR: DO Y AGREE WITH THE
NORMAL WORK DAYS AND TIMES INFORMATION IN THIS SECTION? YES NO
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NAME OF BUSINESS OR INDIVIDUAL HIRING CMB EMPLOYEE EMPLOYEE ID # DEPARTMENT /DIVISION
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JOB TITLE WORK PHONE #
3O$' TYPE OF BUSINESS
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SUPERVISOR ~/~ WORK PHONE #
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NORMAL WORK DAYS AND TIMES DATE OF HIRE
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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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This form has 2 pages - be sure to complete both pages '"
CITY OF MIAMI BEACH
REQUEST FOR APPROVAL OF OUTSIDE EMPLOYMENT -CONTINUED
PAGE2of2
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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 Number E si a re & to
E~ec~d 6 25 $ 3 / og
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By signing below, I certify that I have read this form completely and that I do not have any 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.
EMP SI URE DATE WITNES GNATURE _ 1_
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EMPL EE NAME ID NUMBER
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II. TO BE COMPLETED BY EMPLOYEE'S CITY OF MIAMI BEACH DEPARTMENT
PLEASE CIRCLE ON APPROVED SUPERVI R SIGNATURE & DATE
NAME OF SUPERVISOR DISAPPROVED
PLEASE CIRCLE ON PROVE DIVISION H D SIGNATU 8 DATE
NAM OF DIVISION H D DISAPPROVED
PLEASE CIRCLE ON APPROVED DEPART E AD SI TUR ATE
NAM OF DEPARTMENT
DIRECTOR DISAPPROVED
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PLEASE CIRCLE ONE A OVED CITY MANAGER SIGNATURE & DATE
C Y MANAGER DISAPPROVED ~/~~/~8,
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(f This form has 2 pages - be sure to c~r>fiplelfe oth pages
M:\$CMB\HUMARESO\Outside Employment Form 10 06 03.doc REV: to/osio3