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DIVERSITY STATISTICS REPORTING
Name: l �--- '1 G Gl o �' ,
Board / Committee: Ca L, w 6, i Cr in f 6 / ' Y 4
Appointment Date: / / /'7"
Pursuant to City of,Miami°Beach Ordinance; 2009-3632, the City is required to annually •
prepare and preset a' report`to the City,,C'ommissiori 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 La Femal
' Race/Ethnic Categories s _
What is your race?
`' African-American/Black
Caucasian/White
Asian or Pacific Islander
Native-American/American Indian
Other— Print Race: •
t
Do you consider yourself to be Spanish, Hispanic or Latino/a? Mark the "No"box if not .
Spanish, Hispanic, Latino/a.
LD No
;:gli'1'es
Do:you consider yourself Physically Disabled?
No
.:. Yes •
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Signature: V4, f Date:
F:\CLER\$ALL\aFORMS\BOARD AND COMMITTEES\MISC\BC minority information form 05-20-13 FINAL.doc
Updated: Wednesday,June 25,2014 • •