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DIVERSITY STATISTICS REPORTING
Name: //OA-
(7/1/ •��s
, /2, 7-
Board / Committee:
�' / /
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 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?
African-American/Black
Caucasian/White
D 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.
o
Z3 Yes
•
Do.you consider yourself Physically Disabled?
No
Yes
Si nature: 7—- Date: / Z y
i
F:\CLER\$ALL\aFORMS\BOARD AND COMMITTEES\MISCIBC minority information form 05-20-13 FINAL.doc
Updated: Wednesday,June 25,2014 •