Mayela Mueller!Pr . , _ „
A Al A 1\1\ I E H
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.:DIVERSITY STATISTICS;REPORTING
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Name. / 1147q-e-4(
Board I Committee:
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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 La Female
Race/Ethnic Categories
What is your race?
African-American/Black
Caucasian/White
•
LD 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.
•
No ..
Yes . .
Do you consider.yourself Physically Disabled?
No
. 1 Yes
•
C:\Users\CENTFraN\AppData\Local\Microsoft\Windows\Temporary Internet Files\Content.Outlook\NP4J9CNX\BC minority
information form 05-20-13 FINAL.doc
Updated: Monday,January 26,2015