Dale Stine1;
AA I AM I ; I:._ 7'A' C : :: _ .
DIVERSITY STATISTICS REPORTING . •
•
Name: 1``s c-f l 6 I 0 c •
Board / Committee: G /. ,: T
C
i Z ntment Date:
6- Z:t�
Appo�
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:
t
Gender: Male Female C '
;t
Race/Ethnic Categories
What is your race? {
,African-American/Black 1• ;,
Caucasian/White
Asian or Pacific Islander •
La 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
Yes=
Do.you consider yourself Physically Disabled? -
No _ ,
Yes
•
�Signature: I r __ - ' Date:
, — (1 )— •
F:\CLER\$ALL\aFORMS\BOARD AND COMMITTEES\MISC\BC,minority information form 05-20-13 FINAL.doc
Updated: Wednesday,June 25,2014 '