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Michael Bath
• • M I AAA I t DIVERSITY STATISTICS REPORTING Name: 1 t (c is L frc,,,) 41-kr Board / Committee: 6ac [.) ra s � �(° r Appointment Date: I I / / 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? • _A,,f�-r�'can-American/Black L"Caucasian/White La 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. No D Yes Do,you consider yourself Physically Disabled? No • Yes • Signature: / Date: / . 9 - F:\CLER\$ALL\aFORMS\BOARD AND COMMITTEES\MISC\BC minority information form 05-20-13 FINAL.doc Updated: Wednesday,June 25,2014