Jeremy GreenI .
M 1 AAA I :* irrA H
DIVERSITY STATISTICS REPORTING
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Name: � � � c eAn
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Board / 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.
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Please check the appropriate box for each category:
Gender: Male IOLFemale
Race/Ethnic Categories
What is your race?
African-American/Black
Caucasian/White .,
La Asian or Pacific Islander
Native-American/American Indian
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Other— Print Race:
Do you consider yourself to be Spanish, Hispanic or Latino/a? Mark the "No"box if not
Spanish, Hispanic, Latino/a.
CD No.
Di Yes •
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Do you consider yourself Physically Disabled?
to
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
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