Lindsay Genet ivdmAi bL: ? YIIlh1 t DIVERSITY STATISTICS REPORTING
Name: // Kd ' A !,1
Board / Committee: 1,-4 i; r
Appointment Date: t /
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
, taucasian/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
Do.you-consider yourself Physically Disabled?
No
DYes
Signature: ± ,r 2////
4/./ l Date:
F:ICLER\$ALL\aFORMS\BOARD AND COMMITTEES\MISC\BC minority information form 05-20-13 FINAL.doc
Updated: Wednesday,June 25,2014