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DIVERSITY STATISTICS REPORTING ,
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Name:
Board / Committee: t 1 t)-e R j36-) AIJc..g c &'
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• Appointment Date: Po veA\ � U I
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Pursuant to City of Miami Beach Ordinance 2009-3632, the City is required to annually
prepare and present a report to the City Commission identifying the City's diversity
statistics. This form allows board and committee applicants and members to voluntarily
self-identify their race, ethnicity, disabled status and gender.
Please check the appropriate box for each category: .
Gender: Male Female1
Race/Ethnic Categories
What is your race? '
c_g)effican-American/Black .
Caucasian/White •
Asian or Pacific Islander .
Native-American/American Indian
U Other— Print Race:
Do you consider yourself to be Spanish, Hispanic or Latino/a? Mark the "No"box if not
Spanish, Hispanic, Latino/a.
In Yes
Do you onsider yourself Physically Disabled? -
No
DYes
. C:\Users\CENTFraN\AppData\Local\Microsoft\Windows\Temporary Internet Files\Content.Outlook\NP4J9CNX\BC minority
information form 05-20-13 FINAL.doc •
Updated: Monday,January 26,2015
•