Laurie Kaye Davis .I1C - .. "'7 t 'R" x'lR:P r�:'..¢�J'!!4•r••.rr,wc , .�'; .. ♦.,q«. .n .. •'r -
INA I AM I F u 'c ,
•
DIVERSITY STATISTICS"REPORTING
(Name. l� ,�i y
•
Boa rd / Cornmitee: ti „ 4%/;;) ,..Q (k.)//72/,, s /;-)1/ 1-6 lAiow)en
•
Appointment Date:
•
Pursuant to City of Miami Beach Ordinance 2009-3632,/the is required to annually
• prepare and resent'a�report to the City/Commission identifying--the City's diversity
p p p.
• 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 's
Race/Ethnic`Categories
What is your race?
check the appropriate •Caucasian/White
• int 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.
N o •
'Yes-/ ; . „..k' f` , Y .'
Do"you consider yourself Physically Disabled?
• No
Yes
•y
Signature: � / -� ( J Q '
Date: 11
•
F:\CLER\$ALL\aFORMS\BOARD AND COMMITTEES\MISC\BC minority information form 05-20-13 FINAL.doc
Updated: Wednesday,June 25,2014
•