Jill R. Schockett i\VAVI AAA 1 Ili- ' :: ii* C '; - ", ."
DIVERSITY STATISTICS REPORTING
• Name: ._ , I 1 R 6 0 is p 77
L. Board / Committee: r?�r
(___ - (6) - (
Appointment
Date: / > '7
• 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
ZCaucasian/White .
Asian or Pacific Islander
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.
No . . ► , •
Yes - > A. ti� .
Do.you consider yourself Physically Disabled?
1,21<lo
Yes.
c ? a I' Date: >:'' 1/0 ... l' I / '
Signature. 1� � / .
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F:\CLER\$ALL\aFORMS\BOARD AND COMMITTEES\MISC\BC minority information form 05-20-13 FINAL.doc
Updated: Wednesday,:June 25,2014
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