Maria Maltagliati t\/\ I ANA I ; C H
DIVERSITY STATISTICS REPORTING
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Name. �.� ,� t �
Board / Committee: \- �° I "+ I-; r ,,), 'fr-7
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Appointment Date: /
Pursuant to City of Miami Beach Ordinance 200973632, 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 Z3
Race/Ethnic Categories
What is your race?
African-American/Black
T Caucasian/White
Asian or Pacific Islander
... 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.
21;:s
•
Do.you consider yourself Physically Disabled?
No
Zi Yes
Signature: - .
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F:\CLER\$ALL\aFORMS\BOARD AND COMMITTEES\MISC\BC minority information form 05-20-13 FINAL.doc
Updated: Wednesday,June 25,2014