Marina Aviles •
AAIMA1 COPY
DIVERSITY TATIST1CS REPORTING
Name: kt/t /%t
S
� 7
Board / Committee. aViet fq/ pL i��
Appointment r ointment Date: P /
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 ED Female
Race/Ethnic Categories
What is your race?
Ca African-American/Black
Caucasian/White
La Asian or Pacific Islander
Zi 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.
La No
Yes
•
o.you consider yourself Physically Disabled?
N o
Yes
Signature:
2Z' Date: i is--
F:\CLER\$ALL\aFORMS\BOARD AND COMMITTEES\MISC\BC minority information form 05-20-13 FINAL.doc
Updated: Wednesday,June 25,2014