George Neary IE/&CV!
DIVERSITY STATISTICS REPORTING
iName: (-- ;- tF r- 4�=_ t:.-e~-• i.1 I .
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Board / Committee: , _--/,0- J) , v-r: c,-7;' r < f t:; r
Appointment Date: / ,- - -- dF> •
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: Mal- WI Female
Race/Ethnic Categories
What is your race?
I`-Africari-American/Black
casian/White
ED Asian or Pacific Islander
Native-American/American Indian
0 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 .
D Yes
Do.you nsider yourself Physically Disabled?
No
Yes
S
` '
Signature:
i
Date: //2-,//)
4
F:\CLER\$ALL\aFORMS\BOARD AND COMMITTEES\MISC\BC minority information form 05-20-13 FINAL.doc
Updated: Wednesday,June 25,2014