Lori Gold (' .
DIVERSITY STATISTICS REPORTING
•
Cn t_
Name: o e.A
Board / Committee: I `J ° 3
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 Female IN .
Race/Ethnic Categories
What is your race?
1 African-American/Black
aucasian/White
Asian or Pacific Islander .
EJ 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.
D Yes
Do you consider yourself Physically Disabled?.
[-14 No
IYes
•
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
•