Maria Keller •
f\A I ANA I C
DIVERSITY STATISTICS REPORTING
Name. j. '!�rt/ L,.w / //
F♦
Board
/ Committee4)/ ,,-"/ g - .C 7L,
" 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 bb rd anCl'eommittee 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
Caucasian/White
D Asian or Pacific Islander
Native-American/American Indian
E Other— Print Race:
9
Do you consider yourself to be Spanish, Hispanic or Latino/a? Mark the "No"box if not.
• Spanish, Hispanic, Latino/a.
No
DYes
•
(Do.you_consider yo,urkelf Physically Disabled? ,, , ;
El No
Yes
7 -
� 1, i . Y Date: Z7/720//5.
/ --
Signature: �- ,..
F:\CLER\$ALL\aFORMS\BOARD AND COMMITTEES\MISC\BC minority information form 05-20-13 FINAL.doc
Updated: Wednesday,June 25,2014