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DIVERSITY STATISTICS REPORTING
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Name: -
Board / Committee:
/r-
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 If`�� Female ZJI
;Race/Ethnic Categories
What is your race?
[Z3 African-American/Black
1,411-Caucasian/VVhite
/L3 Asian or Pacific Islander
IA Native-American/American Indian
;<• =Other— Print Race:
Do you consider yourself to be Spanish, Hispanic or Latino/a? Mark the "No"Sox if not ':`
Spanish, Hispanic, Latino/a.
tgNo •
IYes
Do you consider yourself Physically Disabled?
X. N o
Yes
•
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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