Bacallao, Joseph c.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 OFM/AM/ BEACH (CMB) EMPLOYMENT
ID # DEPARTMENT / VISION
EMPLOYEE NAME: LAST NAME, FIRST NAME, MIDDLE NAME
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• WORK PHONE # HOME PHONE #
JOB TITLE '? O S ~O'~ 3
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WORK PHONE # EMPLOYEE'S OTHER PHONE #S (BEEPER, CELL)
SUPERVISOR ?,OS 673 7600
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TO BE COMPLETED BY SUPERVISOR: DO YOU AGREE WITH THE
NORMAL WORK DAYS AND TIMES INFORMATION IN THIS SECTION? YES NO
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B. INFORMATION REGARDING DUTSIDEEMPLOYMENT
NAME OF BUSIN S OR INDIVIDUAL HIRING CMB EMPLOYEE
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SUPERVISOR /
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NORMAL WORK DAYS AN
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RDDRESS 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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this form has 2 pages - be sure to complete both gages ~
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CITY OF MIAMI BEACH '
REQUEST FOR APPROVAL OF OUTSIDE EMPLOYMENT -CONTINUED
PAGE 2 of 2
c.
By signing below,. I cert'-fy 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 SIGNATURE DATE TNESS NATURE
EMPLOYEE NAME 1D NUMBER
II. TO BE COMPLETED BY EMPLOYEE'S CITY OF MIAMI BEACH DEPARTMENT
PLEASE CIRCLE ONE S ERVIS'~R~STt'I & DAT
NAME OF SUPERVISOR DISAPPROVED
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PLEASE CIRCLE O D E & D
NAME MSION HE/A/D/
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i DISAPPROVED / ~
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PLEASE CIRCLE ONE PPROVED DEP EAD SIG TORE 8
NAME OF DEPARTMENT DIRECTOR DISAPPROVED
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PLEASE'CIRCLE ONE A PROVED CITY MANAGER SIG U 8~ DATE
CITY MANAGER DISAPPROVED
This form has 2 pages - be sure to cor~p~ete bo~~i gages
M:ISCMBUiUMARESO10utside Employment Form 10 O6 03.doc REV: to/06/03
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.