Samantha Bratter •
I EAC F-1
DIVERSITY STATISTICS
REPORTING
Name: • �� F. t. .
Board I Committee:
Appointment Date:
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 D Female,
Race/Ethnic Categories
What is your race?
African-American/Black
L 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.
No
Yes
•
Do.you consider yourself Physically Disabled?
No
DYes
,
Signature: Date:
F:\CLER\$ALL\aFORMS\BOARD AND COMMITTEES\MISC\BC minority information form 05-20-13 FINAL.doc
Updated: Wednesday,June 25,2014