David McCauley n
DIVERSITY STATISTICS REPORTING
Name: N a v i . ..!_ 0'a /e7
•
Board / Committee
Appointment Date: 1 / / 'i
1 ( .
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 co`mrrilttee {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
Ill 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. V
TA No ,
Yes ,i,,.
Do.you consider yourself Physically Disabled? •
LD No
►it Yes •
J,-
Z
i D ate: (5/2.(I:Air /
•
•
Signature.
. F:\CLERI$ALL\aFORMS\BOARD AND COMMITTEES\MISC\BC minority information form•05-20-13 FINAL.doc
Updated: Wednesday,June 25,2014 .