Ana Cecilia Velasco f •
M I A M I l'i :._ r r i -
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DIVERSITY STATISTICS REPORTING
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Name:
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- Board / Committee. 4i G ("Ii C , ( Co Vrl 'm ,... le
•
A pp ointment Date: / /7 / /q9/ C-7
/ /
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. /
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Please check the appropriate box for each category: •
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Gender: Male
Female P!!I-
Race/Ethnic Categories
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Wh at is y ou r race? f ;
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. __•D African-American/Black } r t
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` Caucasian/White ifs;) Wit;;_
Asian or Pacific Islander ` .. _
Native-American/American Indian / .
0 Other— Print Race:
Do you consider yourself to be Spanish, Hispanic or Latino/a? Mark the "No"box if not
Spanish, Hispanic, Latino/a.
.
No .
Yes
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Do.you consider yourself Physically Disabled? ,
tk10 No ,.
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D Yes -'- '�
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7 I r \ Date: ? 02,4 /
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F:ICLER\$ALL\aFORMS\BOARD AND COMMITTEES\MISCIBC minority information form-05-20-13 FINAL.doc
Updated: Wednesday,June 25,2014