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Minority Appointment Reporting
Name:
Board 1 Committee:
Appointment Date:
The informaiion requested below is used for yearly reporting required by Florida
State Statute 760.80 (4) Minority representation on boards, commissions,
councils, and committees:
Please check the appropriate box for each category:
Gender:
Male [ ]
Female f 1
Race:
White [ ]
Black [ ]
Ethnic Background:
African-AmericanlBlack [ ]
American Indian or Alaskan Native (]
Asian or Pacific Islander [ I
Hispanic ~ )
White-not Hispanic [ l
Physically Challenged:
Yes [ ]
No ( ]
F:ICLERI5ALL1aFORMStBOARD AND COMMITTEESI6C minoriry information form 02-12-09.doc