Jacquelynn Powers tA
k3 L
DIVERSITY STATISTICS. REPORTING
•
Name: c 11 -' �a v S
Board / Committee
: S - V 6, 4- ( -ems
r
Appointment Date: -i`-1O 9NO 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 Female .....t
Race/Ethnic Categories
What-is your race?
African-American/Black
M Caucasian/White
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.
. . N
DYes
Do.you consider yourself Physically Disabled? V
No
111. .
( y-
Signature: Date:
F:\CLER\$ALL\aFORMS\BOARD AND COMMITTEES\MISC\BC minority information form 05-20-13 FINAL.doc
Updated: Wednesday,June 25,2014 V