Stephen Zack /1\1\ I AAAI E
DIVERSITY STATISTICS REPORTING
Name:
Board / Committee:
1
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
Race/Ethnic Categories
What is your race?
African-American/Black
W Caucasian/W hite •
L1 Asian or Pacific Islander
La 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.
c3 No
Yes .
Do you consider yourself Physically.Disabled?
No
DYes
C:\Users\CENTFraN\AppData\Local\Microsoft\Windows\Temporary Internet Files\Content.Outlook\NP4J9CNX\BC minority
information form 05-20-13 FINAL.doc
Monday,January 26,2015