Elizabeth Schwartz Q.„
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DIVERSITY STATISTICS REPORTING •
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• Name: C 7. 4 J k L Ir r .
Board / Committee: r 4i , I sh i a r
a ,� c.,5. v)-76---vi C..-0 v/1 iv'"' / /tae
Date: / // n_
Appointment f/ ` '
Pursuant to City of Miami Beach Ordinance 2009-36-32, the City is required to annually •
prepare and present-'a/report tfb ;the/C-ity Commissianilde `tifyitrig('th;e 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 0 Female
Race/Ethnic Categories _ i - •
What is your race?
. African-American/Black . •
!.71 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. '.
W No -..''
La Yes V
•
Do.you consider. yourself Physically Disabled?
P.___, No
Yes .
� . - -- Date: 1 1
Signature
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F:\CLER\$ALL\aFORMS\BOARD AND COMMITTEES\MISC\BC minority information form 05-20-13 FINAL.doc ".,.• ,','
Updated: Wednesday,June 25,2014
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