John Turchin CO I Ai V ‘ i
DIVERSITY STATISTICS REPORTING
Name: �"��-�-"� Li Z-C" 4( (
!
Board / Committee.: m
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 'remale
Race/Ethnic Categories
What is your race? .
LZI African-American/Black
CaucasianiWhite
La Asian or Pacific Islander. 7"
La Native-American/American Indian
Other— Print Race:
Do you consider yourself to be Spanish, Hispanic or Latino/a? Mark the "No"box if not
Spanish, Hispanic, Latino/a.
�,.... .3
l Yes
Do.you consider yourself Physically Disabled?
120: 1
Yes
Signature:
Date: 731 )
F:ICLER\$ALL\aFORMS\BOARD AND COMMITTEES\MISC\BC minority information form 05-20-13 FINAL.doc
Updated: Wednesday,June 25,2014