Jessica R. Conn m A to :" ,„
DIVERSITY STATISTICS REPORTING
Name: 6J J ice'
_fryBoard / Committee: � \IVCirnV/1
Appointment l ointment Date: 1 2-(g
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 La Female 7= f
Race/Ethnic Categories
What is your race?
African-American/Black
Caucasian/White
lit; Asian or Pacific Islander
Lh 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
D Yes
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Do.you consider yourself Physically Disabled?
U1 `No
r' Yes
Signature
Date: S ( (
F:ICLER\$ALL\aFORMS\BOARD AND COMMITTEES\MISC\BC minority information.form 05-20-13 FINAL.doc
Updated: Wednesday,June-25,2014
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