Mojdeh Khaghan /V\ t .,< ,44 C 1-1
DIVERSITY STATISTICS REPORTING
Name: LI\0 .Vvc) 1/. 10-
: )kcb
Board / Committee: !M N (_
Appointment Date: 1 1 �/ z73--
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 FemaldtAr
Race/Ethnic Categories .
What is your race? .
African-American/Black
L Caucasian/White .
LD Asian or Pacific Islander
cji Native-American/American Indian
• <I Other- Print Race: NA i, e r-c4<-1-ern
•
Do you consider yourself to be Spanish, Hispanic or Latino/a? Mark the "No"box if not
Spanish, Hispanic, Latino/a.
, No
Yes . .
Do you consider yourself Physically Disabled?
riNo
Yes
•
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