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DIVERSITY STATISTICS REPORTING
Name:
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Board / Committee: /16 c )Ic C„; /ice v.';i m
Appointment Date: c
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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 ca Female _ •
•
Race/Ethnic Categories •
What is your race? .
•
African-American/Black
• • Caucasian/White
Asian or Pacific Islander
L Native-American/American Indian •
Zi 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
Yes •
Signature: -- Date: ��9
•
F:\CLER\$ALL1aFORMS\BOARD AND COMMITTEES\MISC\BC minority information form05-20-13 FINAL.doc
Updated: Wednesday,June 25,2014
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