Seth Feuer • AA I AML, , E4c
DIVERSITY STATISTICS REPORTING
Feuer-
Name: // v r
it:, ` i mil' V ! J G!mittee: :r'cq/,/� /-I (J S,v 5 A .�f
Board / Committee: ,!�
o ,
Appointment Date: ` /
pp 1�
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 xi Female
Race/Ethnic Categories
•
What is your race?
African-American/Black
Caucasian/White
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.
f&-=,iNo ti
Yes .
Do.you consider.yourself Physically Disabled?
No
Yes
Signature•i,/ J Date: fifqii/r-- ..;
•
F:\CLER\$ALL\aFORMS\BOARD AND COMMITTEES\MISC\BC minority information form 05-20-13 FINAL.doc
Updated: Wednesday,June 25,2014 .
•