David Leeds tolAmi n
D Lr r
DIVERSITY STATISTICS REPORTING
7)04 ✓� L CE s
Name. �
Board I
Committee: G
Appointment Date: i 6-7//y
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 E Female
Race/Ethnic Categories
What is your.race? CJ1 :-
Zi African-American/Black
CaucasianNVhite
Zi Asian or Pacific Islander
Native-American/American Indian -- =
E Other- Print Race: -
- i-
-
- - TDo you consider yourself-to be Spanish, Hispanic or Latino/a? Mark the "No''bo'f not
Spanish, Hispanic, Latino/a.
No
Yes
Do.you consider yourself Physically Disabled?
No
La Yes
D /1o1/ols
te: D3
Signature. a
F:\CLER\$ALL\aFORMS\BOARD AND COMMITTEES\MISC\BC minority information form 05-20-13 FINAL.doc
Updated: Wednesday,June 25,2014