Chad Richter - • - , , • , ___ ____ _ ,
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TY STATISTICS REPORTING •
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Name: C h o; d
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Board / Committee: G 0 Li [ e L , 07, , -) ' ..:=c x,..,.,1 0,-,1 I ( a ,ise .-,0 lc r
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Appointment Date: I , 1 5-
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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. •
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Please check the appropriate box for each category:
,.. Gender: Male WeFemale Z3 .
,Race/Ethrilic"Categories (7 / _.....
41 ( 611/t A.,.
What is your race?
1:3 African-American/Black
• [RraUcasian/White
1=3 Asian or Pacific Islander •
1=3 Native-American/American Indian
i Ca Other- 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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11 Yes--/
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Do you consider yourself Physically Disabled?
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FZi Yes , - /
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Signature: Date:
FACLEM$ALL\aFORMS\BOARD AND COMMITTEES\MISC\BC minority information form 05-20-13 FINAL.doc
Updated: Wednesday,June 25,2014
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