Satchell, Isabel
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 C/TYOFM/AM/ BEACH CMB EMPLOYMENT
EMPLOYEE NAME: LAST NAME, FIRST NAME, MIDDLE NAME
s+~~~,e ~t ~..5 ~ I ID #
~~ ~ o~. DEPARTMENT /DIVISION
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JOB TITLE
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x -6~i t g HOME PHONE #
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SUPERVISOR
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~ WORK PHONE #
~,~j ~ 673 EMPLOYEES OTHER PHONE #S (BEEPER CELL
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NORMAL WORK DAYS AND TIMES TO BE COMPLETED BY SUPERVISOR: DO YOU AGREE WITH THE
INFORMATION IN THIS SECTION? ~ YES NO
B. INFORMATION REGARDING OUTSIDE EMPLOYMENT
NAME OF BUSINESS OR INDIVIDUAL HIRING CMB EMPLOYEE EMPLOYEE ID # DEPARTMENT /DIVISION
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JOB TITLE C ~AA WORK PHONE # TYPE OF BUSINESS
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SUPERVISOR ~/ WORK PHONE #
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DATE OF HIRE
NORMAL WORK DAYS AND TIMES
ADORES
S OF BUSINESS: STREET
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STATE / ~ ZIP
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DESCRIPTION OF DUTIES /1~ ~ ~ ( t, ~~„~p ~ ~ e ~e h a-~ d~ se -tom ~3~ ~., S ~ ~,~
WHAT DUTIES MIGHT BE CONSIDERED TO BE A CONFLICT OF INTEREST N'~ ~ ~ ,
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 Employee natur at
D.
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 Ciry Of Miami Beach.
EMPLOYEE SIG URE I DATE WITNESS SIGNATURE
/ EMPLOYEE NAME ID NUMBER
11. TO BE COMPLETED BY EMPLOYEE'S CITY OF MIAMI BEACH DEPARTMENT
PLEASE CIRCLE ONE PPROV D SUPERVISOR SIGNATURE & DATE
NAME OF SUPERVISOR DISAPPnROVED / ,~
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PLEASE CIRCLE ONE APPROVED DIVISION HEAD SIGNATURE & DATE
NAME OF DIVISION HEAD DISAPPROVED
NAME OF DEPARTMENT DIRECTOR PLEASE CIRCLE ONE PPROVED DEPARTMENT HEAD SIGNATURE & DAT
DISAPPROVED Q
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PLEASE CIRCLE ONE PROVED CIT MANAGER SIGNATURE & DATE
CITY MANAGER DISAPPROVED
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This form has 2 pages - be sure toy m to both pages
M:\$CMBIHUMARESO\Outside Employment Form 10 O6 03.doc REV: 10/06/03