Guy Simani / TAfAtV' 1tE eit `a
DIVERSITY STATISTICS REPORTING
6 Name: '
•
f 4�• - {` f • mod '
Board I Committee: (--
r
Appointment Date: /1// •
/ J
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 IZFemale
Race/Ethnic Categories
•
What is your race?
` _African-American/Black V .
Caucasian/White . V V
Li Asian or Pacific Islander V •
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
DYes
Do.you consider yourself Physically Disabled?
No V
• Zi Yes .
Signature: Date: /75‘/I
F:\CLER\$ALL\aFORMS OARD AND COMMITTEES\MISC\BC minority information form 05-20-13 FINAL.doc
Updated: Wednesday, une 25,2014 V