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DIVERSITY STATISTICS REPORTING
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Name: i ---) ,A--- -i , ,..... . / /4)0----,c' 'iii-N
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Board / Committee: i i /
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Appointment Date: •
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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.
1 .
Please check the appropriate box for each category:
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• Gender: Ma Female
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Race/Ethnic Categories .•' • ' . : • •
What is your race?
African-American/Black
,/N Caucasian/White
Asian or Pacific Islander
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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.
• [ i No •• ,
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1,-2-1 Yes • .
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Do you consider yourself Physically-Disabled? .
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,I0 No
Yes
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CAUsers\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 . , •
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