Ronald Starkman _ .,.v - .. .
NA I AAA I .1 I_ C
DIVERSITY STATISTICS REPORTING
/ id/2- >77.50- 144-1
Name:
-71 71
Board / Committee: /76) //AO
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:
g y:
Gender: Male C6 Female
Race/Ethnic Categories
•
What is your race? fr
African-American/Black
.Caucasian/White
Asian or Pacific Islander
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.
N0 •
DYes
Do,you consider yourself Physically Disabled?
No
"-
Signature. /
Date: 2/ /
F:\CLER1$ALL\aFORMS\BOARD AND COMMITTEES\MISC\BC minority information form 05-20-13 FINAL.doc
Updated: Wednesday,June 25,2014