Gail Harris AA IAA A
i • MYERSITY STATISTICS REPORTING
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Board /�Comm
ittee:
Appointment Date: ( 15
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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 youlrrrac'e?- a< ; - /, �r .� ls'�' ` •
l ,
Af ican-American/Black
Caucasian/White
Asian or Pacific Islander •
Native-American/American Indian
Other- Print Race:
•
Do you consider yourself to be Spanish, Hispanic or,Catino/a? Mark the "No"box if not
Spanish, Hispanic, Latino/a.
•
No
La Yes
Do you-con icier yourself Physically Disabled? .
•
rt No
Yes
/.
/. -Date: a J c ow / 5
Signature: 77'- ')//-1:1A/5";-)° 1 /
F:\CLER\$ALL\aFORMS\BOARD AND COMMITTEES\MISC\BC minority information form 05-20-13 FINAL.doc
Updated: Wednesday,June 25,2014 .