Susan Caraballo . , .
. i ' r r---, 17,1 .w:
w M I AM i 0 �' \ .
• L.;, �f Y! :DIVERSITY i'STATISTICS REPORTING
Name: -
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Board / Committee: ' C ,.--p
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Appointment Date: // ' ` I i
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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 IJ Female 4
i , •
Race/Ethnic Categories •
What is your race?
t
African-American/Black
i . Caucasian/White
ca Asian or Pacific Islander .
Native-American/American Indian •
La Other— Print Race:
;I Do you consider yourself to be Spanish, Hispanic or Latino/a? Mark the "No"box if not
Spanish, Hispanic, Latino/a.
\I fs; /4 ,
- Yes:.. �; -
-,,..,
i Do you consider yourself`Physically Disabled?
No tip.. -
D,Yes
P.
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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
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