David Kahn DIVERSITY STATISTICS REPORTING
Name: D a v d <
Board / Committee: CO V1 (en te,i Ad Ui Adsoi7 oil Bd .
Appointment Date:
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 emale
Race/Ethnic Categories
What is your race?
ZI African-American/Black
Caucasian/White
Asian or Pacific Islander
. Native-American/American Indian j
Other— Print Race: Li/0 ''\'S2'#t'C
Do you consider yourself to be Spanish, Hispanic or Latino/a? Mark the "No"box if not
Spanish, Hispanic, Latino/a..
•
L-.3 No \`
Yes • /��
•
Do,you consider yourself Physically Disabled?
No
DYes
•
Signature:
,,/ Date: ,4?Z._.
• F:\CLER\$ALL\aFORMS\BOARD AND COMMITTEES\MISC\BC minority information form 05-20-13 FINAL.doc
Updated: Wednesday,June 25,2014 .
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