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DIVERSITY STATISTICS REPORTING
Name:
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Board / Committee:
Comm, ee.. fr7 0E-
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Appointment Date: 4 a S
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 La Female
Race/Ethnic Categories
What is your race?
l African-American/Black
I, Caucasian/White
[-.D 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
!Yes
Do you consider yourself Physically Disabled? y '
per.
DYes
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C:\Users\CENTFraN\AppData\Local\Microsoft\Windows\Temporary Internet Files\Content.Outlook\NP4J9CNX\BC minority
information form 05-20-13 FINAL.doc
Updated: Monday,January 26,2015 .
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