Jane Dee Gross AA I AM I r
DIVERSITY STATISTICS REPORTING
Name: one
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•
Board / Committee: l- 460c, F(rer . 23 Oa Ci
Appointment Date: C aD l
• of Miami Beach Ordinance 2009-3632, the City is required to annual)
Pursuant to City o Y q annually
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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 h-J1 Female
Race/Ethnic Categories
What is your race?
African-American/Black
Di 17-3 Asian or Pacific Islander •
Zll_Native-American/American Indian
Other- Print Race: fv Mart_
Do you consider yourself to be Spanish, Hispanic or Latino/a? Mark the "No"box if not
Spanish, Hispanic, Latino/a.
i No
Ui Yes .
Do you consider yourself Physically Disabled?
No
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