Judith Berson-Levinson AA I ANA I t, )4%C
DIVERSITY STATISTICS REPORTING
Name: 1 ,� �;P h ` . �r �_� w — e v t) 4,()
Board / Committee: ' _ -- //1-- t-_r Cx- f . a u , 1 .
Appointment Date: / / /�` •
f �
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 krd
Race/Ethnic Categories
•
What is your race?
E £ can-American/Black
Caucasian/White
Ni Asian or Pacific Islander
Za 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.
7
No
LD Yes
Do.you-consider yourself Physically Disabled?
Lai No
Yes
J
Signature:
Date: - , LJ
F:\CLER\$ALL\aFORMS\BOARD AND COMMITTEES\MISC\BC minority information form 05-20-13 FINAL.doc
Updated: Wednesday,June 25,2014