Wendy Unger ‘1::' AVA I A NA l't E A C :? - ..:,.„
, ,
DIVERSITY STATISTICS REPORTING
Name:
Uey
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Board / Committee. r -54 h/ 4 hi ac.....,c_ e ss
& ' i e L
Appointment Date: / / A /f
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 Z3 Female ril •
f f•Race/Ethnic Categories f'
What is your race? , `
African-American/Black . . .
I Caucasian/White
Asian or Pacific Islander .
Native-American/American Indian .
1.Other— Print Race: .
Do you consider yourself to be Spanish, Hispanic or Latino/a? Mark the "No"box if not
Spanish, Hispanic, Latino/a.
._=,.17.4 No
Yes
Do,you consider yourself Physically Disabled? .
No ,,
ni Yes
f
F
\`� Date: 0 // -
�A I
Signature: A. A t
F:\CLER1$ALL\aFORMS\BOARD AND COMMITTEES\MISC\BC minority information form 05-20-13 FINAL.doc
Updated: Wednesday,June 25,2014