testing 10m MIAMIB~EA~H
Name:
Board /Committee:
Appointment Date:
Minority Appointment Reporting
The information 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-American/Black [ ]
American Indian or Alaskan Native [ ]
Asian or Pack Islander [ ]
Hispanic [ ]
White-not Hispanic [ J
Physically Challenged:
Yes [ ]
No [ ]
F:ICLERISALUaFORMSIBOARD AND COMMITTEESIBC minority information form 02-12-09,doc