Laura Veitia - f\Ail ANA I
DIVERSITY STATISTICS REPORTING
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Name: }
Board / Committee: ci L4 fa k.# ► ' �' �/ (Cr ., �,"_ �; 14
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A pp ointment Date: / 1 11
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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
ialliCaucasian/White
izt 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.
o
Yes i
'Do.you consider yourself Physically Disabled?
No
Yes
Signature: At el.2 V•F:\CLER\$ALL\aFORMS\BOARD AND COMMITTEES\MISC\BC minority information form 05-20-13 FINAL.doc
Updated: Wednesday,June 25,2014