Michael I. Feldman •
MIAMI BEACH
DIVERSITY STATISTICS REPORTING
' t
Name: / - t
•
Board / Committee: , ,' •(
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 Ul
• Race/Ethnic Categories
What is your race?
r •
Afx-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 Latino/a? Mark the "No"box if not
Spanish,Hispanic, Latino/a.
I No
D Yes
Do you consider yourself Physically Disabled? •
a No
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