Jack Johnson AA I A its\A I C
DIVERSITY STATISTICS REPORTING
-Name:
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Board / Committee: l � 1 n�►
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Appointment Date: jan . 1q 1015-
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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 Female
Race/Ethnic Categories
What is your race?
La African-American/Black
Caucasian/White •
Asian or Pacific Islander
Native-American/American Indian
Other— Print Race:
• Do you consider yourself to be Spanish, Hispanic or Latino/a? Mark the "No"box if not
Spanish, Hispanic, Latino/a. •
No
Yes •
Do.you consider yourself Physically Disabled?
No •
Ca Yes
Date: (--)- /-)
Signature:
g G,
F:\CLER\$ALL1aFORMS\BOARD AND COMMITTEES\MISc\BC minority information form 05-20-13 FINAL.doc
Updated: Wednesday,June 25,2014