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MIAMI roE4C
DIVERSITY STATISTICS REPORTING
•
Name: ,?IICE 9
Board I Committee: /2e1 1)1/0 /a � � CIL
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Appointment Date:
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 Female{;:)i
Race/Ethnic Categories (' '
ate ories ('
What is your race? •
African-American/Black . i t `,/ 1
Caucasian/White '
Asian or Pacific Islander
Native-American/American Indian
Other— Print Race:
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Do you consider yourself to be Spanish, Hispanic or Latino/a? Mark the "No"box if not
Spanish, Hispanic, Latino/a.
No
Yes
•
Do.you consider yourself Physically Disabled?
s Yes
Signature:
Date: / % )07/
i .
F:\CLER\$ALL\aFORMS\BOARD AND COMMITTEES\MISC\BC minority information form'05-20-13 FINAL.doc .
Updated: Wednesday,June 25,2014