Calvin Kokli DIVERSITY STATISTICS REPORTING
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Name.. � 1..... k
Board / Commrlttee. --\\-\ 1...)•,?...\e.0 $•-)'■.\1.-kjS. -e
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Appointment Date: \ LL \,\
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.
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Please check the appropriate box for each category:
Gender: Male Female
Race/Ethnic Categories
What is your race?
LD African-American/Black
Caucasian/White
Asian or Pacific Islander
Zi 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
LYes •
Do.you c sider yourself Physically Disabled?
No •
Yes
Date:
Signature., r-
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F:\CLER\$ALL\aF, MS\BOARD AND COMMITTEES\MISC\BC minority information form 05-20-13 FINAL.doc
Updated: Wednesday,June 25,2014 •