Loading...
Lonergan, Richard1. TO BE C+t~MPLETE© BY EMPLOYEE -This Farm must be completed & approved prior to beginning any tither employment A. INFORMATION REGARDING CITY OFMIAMt BEACH CMB EMPLOYMENT ID # DEPARTMENT f DIVISION EMPLOYEE. NAME: LAST NAME, FIRST NAME, MIDDLE NAME WORK PHONE # HOME PHONE JOB TITLE pe-t,t ~~ 5ER6'~RIJT gyr7-, ,,~ 3;Z~J WORK PHONE # EMPLOYEE'S OTHER PHONE #S {BEEPER, CELL) jUPERVISOR ~ `. ~-.'..t~ c~S~~~N 6Z_ ~~tssm~ TO BF COMPLETED BY5UPERV/SOR: DO YOU AGREE WITH THE ~NORbRAL WORK DAYS AND TIMES lNFORMi.'S10N IN THIS SECTION? ,~ YES MO ~^l S. INFORMATION REGARDING OUTStDE'EMPLQYME'Ni' EMPLOYEEID# DEPARTMENTlDMSION NAME OF BUSINESS OR INDSVIDUAL HI RING CMB EMPLOYEE C / ,~+ c~ WORK PHONE # TYPE OF BUSINESS J08 TITLE s1 iY o c NONE HI~t3 ,gcliadL SQ,~S'A~ c~oA~ti WORK PHONE # SUPERVISOR (-3 tV O ~~~ .j ~ a-~ m DATE OF HIRE n ~ NORMAL WDRK DAYS AND TIMES F" f ~ 1/FllZi cid4$ ~ ' I ADDRESS OF BUSINESS: STREET ~--' ~ ~ 3 . I C~ ZIT. Q,0 6TY STATE t,l Z!P -~ f`J .~ DESORIPTIDN OF DUTIES L e~,~rr ~'••r>31ti t/s~~'stU3' ~,~p 3'ol~>v,~ Y1aJzfi~~f 6' fT~ f a s i As616~31i1T ~~ms ',NHAT DUTIES MIGHT BE CONSIDERED TO BE A CONFLICT OF INTEREST NON ~ This form has 2 pages - be sure to complete both pages CITY OF MIAMC BEACH REQUEST FOR. APPROVAL OF OUTSIDE EMPLOYMENT -CONTINUED PAGE2of2 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 al} information is sub}ect to investigation and that. falsfication, omission, or misrepresentation is sufficient cause for disciplinary action, up to and including termination.. 1 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 & D. By signing below, I certify that 1 have read this form completely. and that I do not have anv ether employment. 1 understand that before I start any other employment, I must request and obtain the above approvals, I further unders#and that failure to comply with Outside Employment procedures could lead to disciplinary action up fio and including termination of my employment with. the City Of Miami Beach. EMPL EE NA DATE s TNESS SIGNRTU ~~ C ~/~Y/o f/' ~' EMPLOYEE NAME !D NUMBER r7 li. TO BE COMPLETED BY EMPLOYEE'S CITY OF MIAMI BEACH DEPARTMI=NT PLEASE CIRCLE O E APPROVED SuP S SIGNATURE & DATE NAME or' SUPERVISOR ~ DISAPPROVED ~- ~~ ~~~~~E~ ~ ~~ PLEASE CIf2GLE APPROVED ~ Ivi HEAD SkG ATURE & DATE NAME o~ D[vlskoN HEAD ,+~i'7 DISAPPROVED °"`"""" PLEASE CIRGLE ON APPROVED DEPARTMENT HEAD SIGNATURE & DATE NAME Of DEPARTMENT DIRECTQR DISAPPROVED ~~, Y}~ ~~~ C~C~-#~~~ PLEASE CIRCLE UNE AP CITY MANAGER SIGNATURE $ DATE eITY MANAGER _-~,-,." ~'" ~ DISAPPROVED .°'" This form has 2 pages - be sure to complete bo#h pages e~~---~-~` M:t$CMBWUMARESQiOutside Ernptoyment Form 1006 03.doc REV: aotosros