Betsy Malea AA 1 MA I I i .A, C H • .
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DIVERSITY STATISTICS REPORTING
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Name: ," ,, jOilek---/
Board / Committee: Q a . ! ,
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A pp ointment Date: _R
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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.
Please check the appropriate box for each category: •
Gender: Male 1:111 Female li
•
Race/Ethnic Categories
What is your race?
L rican-American/Black
Caucasian/White
La Asian or Pacific Islander
La 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.
i
No
D Yes
Do you consider yourself Physically:Disabled?
V No
J Yes
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information form 05-20-13 FINAL.doc
Updated: Monday,January 26,2015 .