Jonathan Groff r e. .-../ \ ` a' f w r ,
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,,-,, ,. , ,- DIVERSITY STATISTICS REPORTING
C Name: .J �� vl cr + k0 �, rC 1 -
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m m ittee: Pars - k�' € @ r e.c+' I � o ✓�4'/ %r-Q cep, 7 /; oa i
Board / Co .
Appointment Date: / / 1
,:' / /
Pursuant to City of-Miami Beach Ordinance.200\93632, 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 LD Female
• Race/Ethnic.Categories :.; _
What is your race? ,, •
•
Afr' •n-American/Black
aucasian/White
• 0 Asian or Pacific Islander
Native-American/American Indian
- Other– Print Race:
Do you consider yourself to be Spanish, Hispanic or Latino/a? Mark the "No"box if not .
;; . !i1sPan!c Latino/a. •
o /
' DYes - /I/ .
Do.you consider yourself Physically Disabled? ,`; :" .
Y,
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[:_zii,e' P
" - D Yes ' •
Signature: 1■ Date: ///7.4;//5'
, ,4100, 0_,•010P- 7.,:—.. . .
F:\CLER1$ALL\aFORMS\BOARD AND COMMITTEES\MISC\BC minority information form 05-20-13 FINAL.doc
Updated: Wednesday,June 25,2014 . : • • • -
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