Leslie Graff im Am
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DIVERSITY: STATISTICS REPORTING
Name::„
Board / Committee:
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 L.3
• Race/Ethnic Categories
What is your race?
• 1=3 African-American/Black
= iaucasian/White •,
[:=1 Asian or Pacific Islander
Za 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.
/1-6,o
es
Do.you consider yoursilf Physically Disabled? •
•
` rg -No
1:a Yes
- -
Signature
Date: /
yr
FACLEM$ALL\aFORMS1BOARD AND COMMITTEES\MISC\BC minority information form 05-20-13 FINAL.doc
Updated: Wednesday,June 25,2014
_ , • .