Glenn Scott Diffenderfer Minority Report toimAi
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DIVERSITY STATISTICS REPORTING
Name: /40 0 CO Tr- 1/
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Board / Committee: /(` L�i A,649 Pl Boa
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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 Female rej
Race/Ethnic Categories
What is your race?
African-American/Black
Caucasian/White =. .
Asian or Pacific Islander
Native-American/American Indian •
Other— Print Race: 4'
Do you consider yourself to be Spanish, Hispanic or Latino/a? Mark the "No"box if not
Spanish, Hispanic, Latino/a.
VA; No •
Yes
Do:you consider yourself Physically Disabled?
DNo
Yes
•
Signature: N r. Date: 07 779/5
F:\CLER\$ALL\aFORMS\BOARD AND COMMITTEES\MISC\BC minority information form 05-20-13 FINAL.doc
Updated: Wednesday,June 25,2014
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