Dona Zemo •
AA I MA Y,
DIVERSITY STATISTICS REPORTING
Name:
Board / Committee: f
Appointment Date:
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 • •
-ucasian/White
•; Asian or Pacific Islander .
Native-American/American Indian
CD Other— Print Race:
Do you consider yourself to be Spanish, Hispanic or Latino/a? Mark the "No"box if not
Spanish, Hispanic, Latino/a.
►0
D Yes
Do.you consider yourself Physically,Disabled?
Yes
J
Signature:
AL. � � Date: � (;1-1/1
F:\CLER\$ALL\aFORMS\BOARD AND COMMITTEES\MISC\BC minority information form 05-20-13 FINAL.doc
Updated: Wednesday,June 25,2014