Ellen Marchman _- - _ _ _�--_-,. ten... -
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m Am E
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DIVERSITY STATISTICS REPORTING
Name: `a'F
Board / Committee: '. k � r, �.,\ • '.
Appointment Date: f` t T
Pursuant to City of Miami Beach Ordinance 2'009-3632, 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:
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Gender: Male Female
Race/Ethnic Categories
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What is your race?
Ei African-American/Black
Caucasian/White
Asian or Pacific Islander . •
Native-American/American Indian .
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La Other- Print Race:
Do you consider yourself to be Spanish, Hispanic or Latino/a? Mark the "No"box if not
Spanish, Hispanic, Latino/a.
No
La Yes •
Do you consider yourself Physically Disabled? .
t.
ra No
D Yes
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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