Barreiro, George L.3'
CITY OF MIAMI BEACH
REQUEST FOR APPROVAL OF OUTSIDE EMPLOYMC111T -: - __ ~ -
Page 1 of 2 _ .. _ _ _ __ _
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I. TO BE COMPLETED BY EMPLOYEE -This Form must be completed 81 approved prior to
beginning any other employment
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ID # DEPARTMENT /DIVISION
EMPLOYEE NAME: LAST NAME, FIRST NAME, MIDDLE NAME
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WORK PHONE # EMPLOYEE'S OTHER PHONE #S (BEEPER, CELL)
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NORMAL WORK DAYS AND TIMES INFORMATIO SECTION? YES NO
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EMPLOYEE ID # DEPARTMENT /DIVISION
NAME OF BUSINESS OR INDIVIDUAL HIRING CM8 EMPLOYEE
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NORMAL WORK DAYS AND TIMES
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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ThAis form has 2 pages - be sure to complete born 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 alt 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 suffiaent cause for disciplinary action, up to and including termination. I also understand
that 1 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 Nam//e Employee~ID[ Nu/tuber Employee sip Date
D.
II. TO BE COMPLETED BY EMPLOYEE'S CITY OF MIAMI BEACH DEPARTMENT
PLEASE CIRCLE ONE VISOR NATURE 3 DATE
NAME OFSUPERVIS
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R DISAPPROVED
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PLEASE CIRCLE ONE VED TUREbD
NAME OF DIVISION HEAD
- DISAPPROVED
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PLEASE CIRCLE ONE A OVED DEPA HEAD NAT RE & E
NAME OF DEPARTMENT DIRECTOR DISAPPROVED
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PLEASE CIRCLE ONE PROV CITY MANAGER NATI~ZE 8 DATE
CrrY MANAGER
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This form has 2 pages - be sure to p bath pa
M:1sCMBW UMARESOIOutside Employment Form 1006 03.doc REV: 10/06/03
By signing below, I certify that I have read this form completely and that I do not have anv other emplovment. I understand
that fore I start any other empbyment, 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. ,,,,,