Sabrina Cohen inr A I COPY
RAIR/V n
DIVERSITY STATISTICS REPORTING
Name: C ,\
Board
/ Committee:
Appointment Date: kij (
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? -
PAfrican-American/Black
Cam`_
Caucasian/White �-
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.
No
Yes
Do,you consider yourself Physically Disabled?
l\O
UYes
Date:
Signature: U� _�- a
F:\CLER\$ALL\aFORMS\BOARD AND COMMITTEEs\MISC\BC minority information form 05-20-13 FINAL.doc
Updated: Wednesday,June 25,2014