Michael GoldbergI - --- . -----;
/V\ I A NA 1 -1114 r:L t 414
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DIVERSITY STATISTICS REPORTING
Name: LP; aka E I
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Board / Commiftee: vv , . a • ,,,„.
0 i I t 4,,y) 61' i.,?il/4 1"-- • Pi 1")1*$4)ir 4--1 P.\jr tr:1
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Appointment Date: i / 1 1 / '-) •
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Pursuant to City of,Miami Beach Ordinance 2009-3632, the City is required to annually •
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prepare and present 4 a i reporrto the diWctheniiiissibin Adentifying 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: •
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Gender: Male Female
Race/Ethnic-Catedories , , • ' ;
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What is your race?
D African-American/Black
Igi Caucasian/White
Asian or Pacific Islander
CD
Native-American/American Indian . .
• [:=1 Other— Print Race:
• Do you consider yourself to be Spanish, Hispanic or Latino/a? Mark the "No"box if not
• Spanish, Hispanic, Latino/a.
L....1; No
I:3 Yes
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,Do.yom consider yourself Physically Disabled? • ..
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L'-...<.1 No .): . •
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Yes 1.2
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Signature:1'' - Date: \ 4 V- a b) 5
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FACLER\SALL\aFORMS\BOARD AND COMMITTEES\MISC\BC minority information form 05-20-13 FINAL.doc
Updated: Wednesday,June 25,2014 . . ,
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