Freddy Funes •/V\ JAM ' C ,4s K 3 3
DIVERSITY STATISTICS REPORTING
•
}
1
Name: T =..� � 6/1
' �
•
7
Board / Committee: ,�f . �,t � ��� /� s� ,. /Pic
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 g Female
Race/Ethnic Categories
j What is your race?
I
t k t
African-Am"erican/Blac - 4 „; = 4 .
Caucasian/White
Asian or Pacific Islander
LD Native-American/American Indian
Other- Print Race: PE 5Y t te)
Do you consider yourself to be Spanish, Hispanic or Latino/a? Mark the "Np"box if not
Spanish, Hispanic, Latino/a.
1
1No .
""j' ,,•, ,rte±' `�...� _:,��'.
Do.you consider yourself Physically Disabled?
ji4No_ w.
D Yes
Signature:.
/f - Date: V/6/
F:\CLER\$ALL\aFORMS\BOARD AND COMMITTEES\MISC\BC minority information form 05-20-13 FINAL.doc
Updated: Wednesday,June 25,2014