David Lancz . .,,
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DIVERSITY STATISTICS REPORTING -. .
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Name: \ 0 v1 / 1---, . • i---. (/'? L a.
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Board I Committee: f-.3 0 ci 6:7 E I- 641 61 v 1 s 6)1f-Lj ( 4
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Appointment Date: I / / ii "
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Pursuant to City of-Vliami Beach C)rdinance 2009-3632, the City is required to annually •
prepare and preserit ' 'ireigo-i-t to thi-e'biN-'66mmission 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:
Gender: Male._W: Female
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' Race/Ethnic Categories
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What is your race? d
African-American/Black
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Caucasian/White . .
1:3 Asian or Pacific Islander
[Z3 Native-American/American Indian
)f.S42.ther— Print Race:
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Do you consider yourself to be Spanish, Hispanic or Latino/a? Mark the "No"box if not
Spanish, Hispanic, Latino/a.
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No .-... .
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Yes
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Do you consider yourself Physically Disabled? '
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Zi No
[=.1 Yes
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Signature: , c--- ---c, ,,_...----- Date: , 10
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FACLEM$ALL\aFORMS\BOARD AND COMMITTEES\MISCV3C minority information form 05-20-13 FINAL.doc
Updated: Wednesday,June 25,2014
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