Paul Stein /MIA/MI 1E ;
DIVERSITY STATISTICS REPORTING
Name: 1-) `D ►
i
Board / Committee: { �-• .-) k. ,� 4,, , , r; C .* 4< . ! .! - �
Appointment Date: M j 1
i re
Pursuant to City of Miami each Ordinance 2009-3632, the City is required to annually •
prepare and present `a `report to theTCit'y °Coththission 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 ! i Female
Race/Ethnic Categories
What is your race?
African-American/Black
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.
s-No
Yes
Do,you consider yourself Physically Disabled?
No
DYes
Signature: Date: a/ /V'
F:\CLER\$ALL\aFORMS\BOARD AND COMMITTEES\MISC\BC minority information form 05-20-13 FINAL.doc
Updated: Wednesday,June 25,2014
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