Mark Sennreich MIAMI ti'Aik\ C
fix` R
DIVERSITY STATISTICS REPORTING
Name: G/
Board / Committee: //c /46 -f cil 171%J A 1 or
Appointment Date: - I t ° S
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(A
Race/Ethnic Categories
What is your race?
Li African-American/Black
53 Caucasian/White
Lai Asian or Pacific Islander
Ca Native-American/American Indian •
Zji Other— Print Race:
Do you consider yourself to be Spanish, Hispanic or Latino/a? Mark the "No"box if not
Spanish, Hispanic, Latino/a.
4' No
Yes
• Do you consider yourself Physically Disabled? t<< '"j
al No
•ali Yes
C:\Users\CENTFraN\AppData\Local\Microsoft\Windows\Temporary Internet Files\Content.Outlook\NP4J9CNX\BC minority
information form 05-20-13 FINAL.doc
Updated: Monday,January 26,2015
L •