Patricia Frost / V ‘ I MNA 0. EAL irl
t, ,----) _ DIVERSITY STATISTICS 'REPORTING
/1 0 1'7 I cia... ii-,,-,.: 1 6:7s/
Name: / d t e 5.. ,
•
1 hi Board / Committee.. � Y u5/ ?l el ces
c
Date: /0/° (/
,, �'4. Appointment 2 ,"
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 .
I self-identify their race, ethnicity, disabled status and gender. l -`-
Please check the appropriate box for each category:
i
Gender: Male,D Female :
Race/Ethnic Categories - .t .� .
What is your race?
L
LD African-America ., f
na)_ck �-max�.;�, .::
. Caucasian/White, , ., `' ,
Asian or Pacific Islander `"
La Native mA erican/American Indian
Ca Other- Print Race: -�f
f Do you consider yourself to-be Spanish, Hispanic or Latino/a ark the "No"box if not
Spanish, Hispanic, L no/a.
� No
Yes-`.--
/Do.you consider yoursel ysically Disabled?
,/t
N o ,-'
Yes !�'
Date: l7 �l S
Signature: ,,. .r �.
F:\CLER\$ALL\aFORMS\BOARD AND COMMITTEES\MISC\BC minority information form 05-20-13 FINAL.doc •
Updated: Wednesday,June 25,2014