Tumbleson, Mathew S.Fl ~E
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
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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)
SUPERVISOR
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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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B. INFORMATION REGARDING OUTS/DEEMPLOYMENT
EMPLOYEE ID # DEPARTMENT /DIVISION
NAME OF BUSIN
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VIDUAL HIRING CMB EMPLOYEE
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JOB TITLE WORK PHONE #
~~~~~~ TYPE OF BUSINESS
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WORK PHONE #
SUPERVISOR
DATE OF HIRE
NORMAL WORK DAYS AND TIMES
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ADDRESS OF BUSINESS: STREET
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CITY STATE ZIP ,--r;
DESCRIPTION OF DUTIES N ~ I
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WHAT DUTIES MIGHT BE CONSIDERED TO BE A CONFLICT OF INTEREST
This form has 2 pages - be sure to complete both pages
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 E to e i at to
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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.
EM L E GN TURE DATE WITNESS SIGNATURE
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EMPLpYEE NAME• ID NUMBER
II. TO BE COMPLETED BY EMPLOYEE'S CITY OF MIAMI BEACH DEPARTMENT
PLEASE CIRCLE ONE PR VED ERVISO SIGNATU ~ A
NAME OF SUPERVI OR ~
~an DISAPPROVED
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9D LEASE CIRCLE O E APPROVED
DISAPPROVED IVISI HEAD S GNATURE & AT
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PLEASE CIRCLE APPR VE DEP TMENT HEAD SIGNATURE & DATE
NAME OF DEPARTMENT DIRECTOR DISAPPROVED (t < <
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PLEASE CIRCLE ONE PROV CITY MANAGER SIGNATURE & DATE
CITY MANAGER DISAPPROVED
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This form has 2 pages - be sure to c~mple'~e A~th pages
M:\$CMB\HUMARESO\Outside Employment Form 10 06 03.doc REV: 10/06/03