Mia R. Glick~_ f ~,j ~, { ~,~~11 ~ ~ ~~~ ~ CiTY OF MIAMC BE~,CEJ
BOARD AND COMMITTEE APPLICATION FORM
NAME: GI l G K,. M i a ¢Z.
Last Name n First Name Middle Initial
HOME ADDRESS: ~"I ~D O l-Q Ke v [ e~ ~`R . 1'Y1, t' ~l~ ~'3 ~ I--~-('
Apt No. ~ t House No.lStreet City ~ St/ate~ Zip Code
PHONE: 3~S~~~o~v -~l-f~5 ~OS-~~5' QS~Sq (YIIG~,p-~ GL L°`-'~e ,COi~'~
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Business Name
Address:
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Position: ~ ~Cil C ~e. ~
No/1 I~. Street/ ~""~ pC~ity State Zip Code
Professional License (describe) Ce.~r ~ ` r lX C_.S 1l b G Gl rt,'C~~:V ?~p~s: Attach a copy of the license
Pursuant to City Code section 2-22(4) a and b: Members of agencies, boards, and committees shall be affiliated with the city; this
requirement shall be fulfilled in the following ways: a) an individual shall have been a resident of the city for a minimum of six
months; or b) an individual shall demonstrate ownership/interest for a minimum of six months in a business established in the city.
• Resident of Miami Beach for a minimum of six (6) months: Yes~or No ^
• Demonstrate an ownership/interest in a busines~i Miami Beach for a minimum of six (6) months: Yes~or No ^
• Are you a registered voter in Miami Seach: Yes f~er No D
• (Please circle one): I am now a resident of: North Beach South Bsach Middle Beach
• I a ap lyin for an appointment because I have sppe~cial abilities, knowledge and e~e 'ep nce. ease ~s elow:
~/ ~ b ~ ~ rc:~M m ~ v1 ~ ~ NZ~ v'~, ~ ate, te.o'v'~
• Are you pre ently~- registered lobbyi wit the City of Miami Beach? es D or o
Please list your preferences in order of ranking [1j first choice [2] second choice, and [3j third choice. Please note that only three f3)
choices will be observed by the Clty Clerk's Office. (Regular Boards of City)
^ Affordable Housin Adviso Committee ^Housin Autho
^ Art in Public Places Committee ^ Loan Review Committee
D Beautification Committee ^ Marine Autho
^ Board of Ad'ustment' D Miami Beach Commission for Women
^ Bud et Adviso Committee ^ Miami Beach Cultural Arts Council
^ Ca itai im rovements Pro acts Oversi ht Committee ^ Miami Beach Sister Cities Pro ram
^ Committee on the Homeless D Normand Shores Local Govemmerrt Nei h. Im rovement
Committee for Qual' Education in MB ^ Parks and Recreation Facilities Board
^ Commun' Deveio ment Adviso ^ Personnel Board
Communit Relations Board ^ Plannin Board'
^ Convention Center Adviso Board ^ Police Citizens Relations Committee
^ Debarment Committee ^ Production Indus Council
^ Desi n Review Board` ^ Public Safe Adviso Committee
^ Disabili Access Committee ^ Safe Committee
Fine Arts Board ^ Sin le Famil Residential Review Panel
^ Ga ,Lesbian, Bisexual and Trans ender GLBT ^ Sustainabil' Committee
^ Golf Adviso Committee ^ Trans aren Reliabili & Accountabil' Committee °TRAC"
^ Health Adviso Committee ^ Trans ortation and Parkin Committee
^ Health Facilities Autho ' Board ^ Visitor and Convention Autho
^ His anic Affairs Committee 0 Waterfront Protection Committee
^ Historic Preservation Board ^ Youth Center Adviso Board
"Board Required to.Flle State Disclosure Form
Note: If applying for Youth Advisory Board, please indicate your affiliation with the Scott Rakow Youth Center.
1. Past service on the Youth Center Advisory Board: Yes ^ No ^ Years of Service:
2. Present participation in Youth Center activities by your children YesC~ No ^. If yes, please list the names of your children, their
ages, and which programs. List below:
Child's name: Age: Program:
Child's name:
Age: Program:
F:\CLEP.\$ALL\aFORMS\BOARD AND COMMITTEES\BC Application062609 NEW.doc
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.Have you ever been convicted of a felony: Yes :- or N~ If yes; please explain in detail:
• Do you currently have a violation(s) of City of Miami Beach codes: Yes ~ or ~ . If yes, please explain in detaiL•
• Do you currently owe the City of Miami Beach any money: Yes 0 or No~lf yes, explain in detail
• Are you currently serving on any City Boards or Committees: Yes r or No~f yes; which board?
• What organizations in the City of Miami Beach do you currently hold membership in?
Name:
Name:
Title:
Title:
• List all properties owned or have an interest in, which are located within the City of Miami Beach:
~ 6 l_.a ~Ce v ~ v~ ~Dv } v-Q.
• I am now employed by the City of Miami Beach: Yes ^ or No~.Which department?
• Pursuant to City Code Section 2-25 (b): Do you have a parent ~, spouse G, child G, brother G, or sister 0 who is employed by the
City of Miami Beach? Check all that apply. Identify the department(s): ~ r~
The following information is voluntary and is neither part of your application nor has any bearing on your consideration for appointment. It is
being asked to comply with federal equal opportunity reporting requirements.
Gender: 0 MaleFemale
Ethnic Origin: Check one only (1)
`~-IAthlte (Not of Hispanic Origin): All persons having origins in any of the original peoples of Europe, North Africa or the Middle East.
^ African-American/Black (Not of Hispanic Origin): All persons having origins in any of the Black radal groups of Africa.
^ Hispanic: All persons of Mexican, Puerto Rican, Cuban, Central or South American, or other Spanish culture or origin, regardless of race.
^ Asian or Pacific islander: All persons having origins in any of the original peoples of the Far East, Southeast Asia, the Indian Subcontinent, on
the Padfic islantls. This area indudes, for example, China, India, Japan, Korea, the Philippine Islands and Somaa.
^ American Indian or Alaskan Native: All persons having origins in any of the original peoples of North America, and who maintain
Cultural identification through tribal affiliation or community recognition.
Yes ^ or
Employment Status: Employed Retired C Homemaker ^ Other ^
NOTE: If appointed, you will be required to follow certain taws which apply to city boardlcommittee members.
These laws include, but are not limited to, the following:
o Prohibition from directly or indirectly lobbying city personnel (Miami Beach City Code section 2-459).
o Prohibition from contracting with the city (Miami-Dade County Code section 2-11.1).
o Prohibition from lobbying before boardlcommittee you have served on for period of one year after leaving office (Miami
Beach City Code section 2-26).
o Requirement to disclose certain financial interests and gifts (Miami-Dade County Code section 2-11.1).
(re: CMB Community Development Advisory Committee): prohibition, during tenure and for one year after leaving office,
from having any interest in or receiving any benefit from Community Development Block Grant funds for either yourself ,
or those with whom you have business or immediate family ties (CFR 570.811 }.
Upon request, copies of these laws may be obtained from the City Clerk.
"I hereb att $o the accuracy and truthfulness of the application and have received, read and will abide by Chapter 2,
Artic t Clty Code "Standards of Co duct or City Officers, Employees and Agency Members."
~ D ~l i, r C.~ (Yl (~(1 SIC, ~`'( )~ot
Applicant's , gnature D e ~ Name of Applicant (PLEASE PRINT)
Please attach a copy of your resume to this application
NOTE: Applications will rem on file f r a period of one (1) calendar year.
Received in the City Clerk's Office by : Date: _; /2009 Control No.i Date: ~ / 009
Name of Deout Clerk
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Ii/~ia Glick
profile
Mia was born in Miami and has lived in Miami Beach since 1988. She teaches Prenatal yoga and enjoys
serving on the board of PTA at North Beach Elementary. She is the model in an official poster for the city of
Miami.
experience
VP OF PROGRAMMIFIG, R10RTP4 Q3EAC1.1 ELEMERITARY PYA-2007- PRESERIT
has been apart of PTA as advocacy and programmingVP.Also served on EESAC committee at school.
PRERIATAL YOGA IR7STRUCTOR, BROVNIdES, LIRICOLN' RD- a YEARS
Teach yoga to pregnant women.
P9ATh1A YOGA, KAUFMAW !~ ROSSIia1, COCOWUT GRObE -4 YEARS
Teach Corporate yoga
IFASId10R1 MODEL, MIAMI 6EACP4 SlietCE 1984
has worked in NewYorkand all over the world as a fashion model.
~duca~ion
FIU, Hotel Restaurant Management Graduated in 1992
KundaliniYoga Certification (3H0) 1995
Skills
Yoga & Mediation, Knitting
deferrals
Laura Levey 305-905-2680
Mariana Cruz 786-417-4750
Ivette Borrello 305-562- 1675
496o Lakeview Dr Miami Beach, FL 33i4o T: 3oS 495-9589 wwwyogawithmia.com miapta@me.com