David B. Smith AINA. 1t1
DIVERSITY STATISTICS REPORTING
atA, 4,-(A
Name:
•
Board / Committee:
C
rel
c_c 01-Q■
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 I Female
Race/Ethnic Categories
•
What is your race?
IZJI African-American/Black
Caucasian/White
Asian or Pacific Islander
•
EJ 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.
:=3-No
La Yes
Do you consider yourself Physically Disabled?
No
UYes
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
•
•