Scott Needelman •
t\A I A/V\ H
DIVERSITY STATISTICS REPORTING
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Board / Committee: 1---f ‘D Toel(4.- e- I/00 i(?)
Appointment Date:
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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 6— Female�!
Race/Ethnic Categories
What is your race?
L1 African-American/Black •
Caucasian/White
Ll Asian or Pacific Islander
La Native-American/American Indian
Other— Pr.int Race:
Do you consider yourself to be Spanish, Hispanic or�Latino/a? Mark the "No"box if not
Spanish, Hispanic, Latino/a.
No
Yes
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Icier 6 irself Physically Disabled?
D,ofyou�con ies .,o y y
miNb
I=J 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
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