Antonio Purrinos •
M I AM
DIVERSITY STATISTICS REPORTING
Name: tJ /-0 Pt) fr-) ,5
/—/ / a 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 LLB Female
Race/Ethnic Categories
What is your race? _
• African-American/Black
UCaucasian/White
Asian or Pacific Islander
Native-American/American Indian
Other— Print Race:
•
Do you consider yourself to be Spanish,tlispanic or Latino/a? Mark the "No"box if not
Spanish, Hispanic, Latino/a.
�No
DYes
•
Do.you consider yourself Physically Disabled? .
No
I:3 Yes
--•��.,:.�--�-�-Y,�b Date: � . d. % ����,�\r"Signature.: ----
•
F:\CLER1$ALL\aFORMS\BOARD AND COMMITTEES\MISC\BC minority information form 05-20-13 FINAL.doc
Updated: Wednesday,June 25,2014