Omar R. Caiola CA p\A i r... ' !AA I I Ilk ii tk ' H - • - ,,„... ,
DIVERSITY STATISTICS REPORTING
1 , ,
Name. 1410 it Z eet c 611>‘
Board / Committee: PI 1.c4 R r t'3 r
Appointment Date: 2/z /
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: Mai Female ] •
•
Race/Ethnic Categories
;: What is your race?
D African-American/Black •
CaucasianNVhite
p 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.
LD No
P`Yes
•
Do,you consider yourself Physically Disabled? .
Yes
) .
Signature: Date: 2 Is
/s---
F:\CLER\$ALL\aFORMS\BOARD AND COMMITTEES\MISC\BC minority information form 05-20-13 FINAL.doc
Updated: Wednesday,June 25,2014
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