Elizabeth Camargo •
NA Ami
DIVERSITY STATISTICS REPORTING
Name: 'bt: A-13 a14 CAA✓ C-o
- Board / Committee: DC-
Appointment Date: MP L 20 14-
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?
African-American/Black
Caucasian/White
EZI Asian or Pacific Islander
Native-American/American Indian
ILD 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?
aNO
Yes
Signature: t-- -'L�'ti�. .: -,o
Date: oa /03
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F:\CLER\$ALL1aFORMS\BOARD AND COMMITTEES\MISC\BC minority information form 05-20-13 FINAL.doc
Updated: Wednesday,June 25,2014 .
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