Carol HousenI� _ _._ _ �. ,t.,y.:rt:,rr.f.a.n; it�i.'7tl'+r. f, p,,,: .5•-yr!^6"+fw,�R",•�7"1.7..-�.��� :,T .. ..qt.. .: ,V ; 'R . .. _
MIAMI •
DIVERSITY STATISTICS REPORTING
Name.
Board / Committee:
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
Race/Ethnic Categories
What is your race?
E African-American/Black
-Caucasian/White
La Asian or Pacific Islander
Native-American/American Indian
Other— Print Race: ' " 99
Do you consider yourself to be Spanish, Hispanic or Latino/a? Mark the "No"box if not
Spanish, Hispanic, Latino/a.
43N0
i—jYes
•
Do,you consider yourself Physically Disabled?
1 Flo'-"~- •
ca Yes
•
r �' �r ,�_-�� �=� �� ` �'---..._��1- Date: � � I
Signature: .
F:\CLER\$ALL\aFORMS\BOARD AND COMMITTEES\MISc\BC minority information form 05-20-13 FINAL.doc
Updated: Wednesday,June 25,201'4