Steven Adkins rTY-P.f1r 7.)1+1:-,yQ9'yL'9S•ii 11P!`(),L`T.il.A;.1` e:f.. � �r i;1y.r- i ... r\. ;r..Y T1 -//
IV\ I Af\A IA* E n .
DIVERSITY STATISTICS REPORTING
J1
Name: - ``- ,/
Board / Committee. CI S "Tc.
C CT ( S
Appointment Date: a
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 Female
Race/Ethnic Categories
What is your race?
frican-American/Black
F-2_; Caucasian/White
D Asian or Pacific Islander ' ..
Native-American/American Indian
E 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
La Yes •
•
Do.you consider yourself Physically Disabled?
No •
Yes
re: Date: l3 Ii
)
Signature:
F:\CLER\$ALL\aFORMS\BOARD AND COMMITTEES\MISC\BC minority information form 05-20-13 FINAL.doc
Updated: Wednesday,June 25,2014