David Cardenas •
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I E
I A - C
DIVERSITY STATISTICS REPORTING
Name: �,...� G�v ( N
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Board / Committee: �I/ f=>Lr,1 �G /f
Appointment Date r ,/ a •
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 .
•
Race/Ethnic Categories
What is your race?
African-American/Black
taucasian/White
D Asian or Pacific Islander .
Native-American/American Indian
• - D 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
La s •
Do,you consider yourself Physically. Disabled?
No •
Yes •
Si g nature: a Date: z .es. z,/<
F:\CLER\$ALL\aFORMS\BOARD AND COMMITTEES\MISC\BC minority information form 05-20-13 FINAL.doc
-• Updated: Wednesday,June 25,2014