Richard Cuello-Fuentes •
IMIAtv\ I a., ..a
DIVERSITY STATISTICS REPORTING
•Name: L t. - Y
Board 1 Committee: e f 'A- 1 c,
Appointment Date:
/ 1
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 LFemale
Race/Ethnic Categories
What is your race?
African-American/Black
Caucasian/White
C3 Asian or Pacific Islander
Native-American/American Indian
ID Other— Print Race:
Do you consider yourself to be Spanish, Hispanic or Latino/a? Mark the "No"box if not
Spanish, Hispanic, Latino/a. f 1 `
No
,Yes
Do.you consider yourself Physically Disabled?
'I No
DYes -
Signature: Date: _s .
F:ICLER\$ALL\aFORMS\BOARD AND COMMITTEES\MISC\BC minority information form 05-20-13 FINAL.doc
Updated: Wednesday,June 25,2014