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Erin Gaskin 12/31/2018MIAMIBEACH City of Miami Beach, 1700 Convention Center Drive, Miami Beach, Florida 33139, www.miamibeachfl.gov OFFICE OF THE CITY CLERK, Rafael Granado, City Clerk Tel: (305) 673-7411, Fax: (305) 673-7254 Email CityClerk@miamibeach.gov January 20, 2017 Ms. Erin Gaskin 1395 Brickell Avenue, 14th FL Miami , Florida 33131 SUBJECT: Human Rights Committee Dear Ms. Erin Gaskin: Congratulations! You have been appointed by Mayor Philip Levine to the agency, board or committee named above for a term ending: 12/31/2017. Pursuant to City of Miami Beach Code Section 2-22 (5)a,"Notwithstanding any other provision of the City Code or of any resolution, commencing with terms beginning on or after January 1, 2007, the term of every board member who is directly appointed by a member of the City Commission shall automatically expire upon the latter of: December 31 of the year the appointing City Commissioner leaves office or upon the appointment/election of the successor City Commission member." If you are unable to accept this appointment, or have any questions, please call the Office of the City Clerk at 305.673.7411. Please read the enclosed materials carefully. Congratulations again and good luck. Regards, Rafael Granado City Clerk cc: Saul Frances, Parking Director Marcia Monserrat, City Liaison ATTACHMENTS: Letter of Appointment Oath City Code/Ordinance section applicable to agency, board or committee City Code Section 2-22, 2-23, 2-24, 2-25, 2-26, 2-458 and 2-459 Ordinance No. 2006-3543 - Amendment to City Code Section 2-22 Miami -Dade County Code Section 2-11.1 - Conflict of Interest and Code of Ethics City Wide Permit Application - (Parking Department Form) Booklet - Guide to the Sunshine Amendment and Code of Ethics for Public Officers and Employees We are committed to providing excellent public service and safety to all who live, work and play in our vibrant, tropical, historic community. MIAMIBEACH City of Miami Beach, 1700 Convention Center Drive, Miami Beach, Florida 33139, www.miamibeachfl.gov OFFICE OF THE CITY CLERK, Rafael Granado, City Clerk Tel: (305) 673-7411, Fax: (305) 673-7254 Email CityClerk@miamibeach.gov TO: Ms. Erin Gaskin RE: Human Rights Committee do solemnly swear or affirm to bear true faith, loyalty and allegiance to the Government of the United States, the State of Florida, and the City of Miami Beach, and to perform all the duties of a member of the above-mentioned board or committee of the City of Miami Beach to which I have been appointed for a term ending: 12/31/2017. I have been issued a copy of section 2-11.1 of the Miami -Dade County Code (Conflict of Interest and Code of Ethics Ordinance), as well as Florida Commission on Ethics Guide to the Sunshine Amendment and Code of Ethics for Public Officers and understand that as a member of a City of Miami Beach Board and/or Committee, I must comply with the financial disclosure* requirements of Miami -Dade County or the State of Florida (depending on the board or committee on which I serve) on July 1st, fo •wing the closing of the calendar year on which I have served. in Gaskin Sworn to and subscribed before me this 3day of Scs>1 , 2017 amon Quezada en—uty Clerk *Please visit the City of Miami Beach website at www.miamibeachfl.gov under City Clerk/Board and Committees for additional information regarding the Financial Disclosure Requirements. We are committed to providing excellent public service and safety to all who live, work and play in our vibrant, tropical, historic community. MIBEACH -grmie-i;L BOARD AND C fnufLP Q Arh on t1Mgfa r i :E: APPLICATION FORM Last Name gs� M.i aeJ 54, Home Address First Name gal ` 3ca '12}71E-q?yy 30c7 c2_1q Home Telephone , Work Telephone wh'—i 3 urn cl-t City State 79y Business Name Cellular Telephone State Occupation /315' p;ric,kr1! Ave,1 PCoar /jtvwtt Business Address City Professional License (describe): P)6 CLO. '7G(% 1'14044.4 Expires: Please attach a copy of currently effective professional license. Middle Initial 331 Li1 Zip Code e y as k«ti� J Email address w kr= 3J3/ Zip Code Pursuant to City Code section 2-22(4)a & b: Members of agencies, boards and committees shall be affiliated with the City. This requirement shall be fulfilled in the following ways: a. An individual shall have been a resident of the City for a minimum of six months; or b. An individual shall demonstrate ownership/interest for a minimum of six months in a business established in the City for a minimum of six months. • Resident of Miami Beach for a minimum of six (6) months: Yes or No LZli • Demonstrates ownership/interest in a business 'n iami Beach for a minimum of six months: Yes LJi or No • Are you a registered voter in Miami Bach: Yes or No Zji • I am now a resident of: North Beach fps South Beach La Middle Beach Zit • I a applying for an appointment b c use I haverp cl bilities, knowledge and experience. Please list b low: be yl . /- t a 1 4 CA/(/ j'a41 1414114 2 i ij tlia Jother( 17aW4,,OhA • Are you presently a registered lobbyist with the City of Miami Beach? Yes Zii or No Please list your preferences in order of ranking [1] first choice [2] second choice, and [3] third choice. Please note that only three (3) choices will be observed by the Office of the City Clerk. ❑ Affordable Housing Advisory Committee 0 Health Advisory Committee p Parks and Recreation Facilities Board O0 ❑ Art in Public Places Committee `$jHealth Facilities Authority Board 0 Personnel Board ❑ Audit Committee 0 Hispanic Affairs Committee❑ Planning Board** ❑ Board of Adjustment ** 0 Historic Preservation Board* 0 Police Citizens Relations Committee 0 Budget Advisory Committee 0 Housing Authority 0 Production Industry Council ❑ Committee on the Homeless XI Human Rights Committee 0 Sister Cities Program ❑ Committee for Quality Education in MB 0 LGBT Advisory Committee XSustainability Committee ❑ Convention Center Advisory Board 0 Marine & Waterfront Protection Authority 0 Transportation, Parking, & Bicycle -Pedestrian Facilities Committee ❑ Cultural Arts Council 0 Miami Beach Commission for Women 0 Visitor and Convention Authority ❑ Design Review Board* 0 Normandy Shores Local Government Neighborhood Improvement 0 Youth Commission ❑ Disability Access Committee * Board members are required to file Form 1 — "Statement of Financial Interest" with the State. * If you seek appointment to a professional seat (e.g., lawyer, architect, etc.) on the Board of Adjustment, Design Review Board, Historic Preservation Board or Planning Board, attach a copy of your currently -effectively license, and furnish the following information: �,,.,�Jj� Type of Professional License """" License Number /c '3 iL License Issuance Date 5el1 `/-c (Y-Ia /19 1 License Expiration Date jai Page 1 of 4 F:\CLER\$ALL\aFORMS\BOARD AND COMMITTEES\BC APPLICATION REVISED 06142016.docx I -1c turn °° Note: If applying for the Youth Cen = positions of the Parks and Recreations Facilities Board, please indicate your affiliation with the Scott Rakow Youth Center and/o e North Shore Parks Youth ear: r: Please describe your past service with the Cit `.. Youth Ce • ers (include dates of service): Present participation in Youth Center activities b, your ch ,. ren: Yes 0 No 0 If yes, please list below the names of your ildren, their ages '= d the programs in which they participate: Child's name: Age: Child's name: Age: Program: Program: • Have you ever been convicted of a felony? Yes 0 or No If yes, please explain in detail: \; • Do you currently have a violation(s) of City of Miami Beach Code? Yes 0 or N. 47; If yes, please explain in detail: • Do you currently owe the City of Miami Beach any money? Yes 0 or No 41 If yes, explain in detail: • Are you currently serving on any City Board or Committee? Yes 0 or No If yes, which board/committee? • In what organization(s) in the City of Miami Beach do you currently hold membership? Name Position Name Position • List aI prope l,es owned or inwhich ou have interest within the City of Miami _peach: �a +� S x61 �t,ti cl Sree1 MO. FL. '33/ 41 • Are you now employed by the City of Miami Beach? Yes or No tN Which department and title? • Pursuant to City Code Section 2-25 (b1±5o Do youave a parent Li, spouse 0, child L011 brother 01 or sister 101 who is employed by the City of Miami Beach? Yes or No If "Yes," identify person(s) and department(s): The following information is voluntary and is neither part of your application nor has any bearing on your consideration for appointment. It is being asked to comply with City diversity reporting requirements. Gender: Male Li Female I Race/Ethnic Categories IWhat is your race? 41 African-American/Black Caucasian/White Asian or Pacific Islander Native-American/American Indian Page 2 of 4 F:\CLER\$ALL\aFORMS\BOARD AND COMMITTEES\BC APPLICATION REVISED 06142018.docx La 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? NOTE: IF APPOINTED, YOU WILL BE REQUIRED TO FOLLOW CERTAIN LAWS THAT APPLY TO CITY BOARD/COMMITTEE MEMBERS. THESE LAWS INCLUDE, BUT ARE NOT LIMITED TO: o Prohibition from directly or indirectly lobbying City personnel (Miami Beach City Code section 2-459). o Prohibition from contracting with the City (Miami -Dade County Code section 2-11.1). o Prohibition from lobbying before the board/committee you have served on for period of one year after leaving office (Miami Beach City Code section 2-26). o Requirement to disclose certain financial interests and gifts (Miami -Dade County Code section 2-11.1). o CMB Community Development Advisory Committee: prohibition, during tenure and for one year after leaving office, from having any interest in or receiving any benefit from Community Development Block Grant funds for either yourself, or those with whom you have business or immediate family ties (CFR 570.611). o Sunshine Law - Florida's Government -in -the -Sunshine Law was enacted in 1967, Today, the Sunshine Law regarding open government can be found in Chapter 286 of the Florida Statutes. These statutes establish a basic right of access to most meetings of boards, commissions and other governing bodies of state and local governmental agencies or authorities. o Voting conflict — Form 8B is for use by any person serving at the county, city or other local level of government on an appointed or elected board, council, commission, authority or committee. It applies equally to members of advisory and non -advisory bodies who are presented with a voting conflict of interest under Section 112.3143, Florida Statutes. Upon request, copies of these laws may be obtained from the City Clerk. I HEREBY ATTEST TO THE ACCURACY ND TRUTHFULNESS OF THE APPLICATION; AND I HAVE RECEIVED, READ AND WILL ABIDE BY CH/�P�ER 2, ARTICL 11, OF THE MIAMI BEACH CITY CODE, ENTITLED "STANDARDS OF CONDUCT FOR CITY OFFICERS, EMPL¢YEES AND ENCY MEMBERS AND ALL OTHER APPLICABLE COUNTY AND/OR STATE LAWS AND STATUTES ACC 71,GLY." Applicant's Signatu 1.36 ..17 b, Date Name of Applicant (PLEASE PRINT) Received in the Office of the City Clerk by: Name of Deputy Clerk Control No. Date ATTACH A CURRENT RESUME, PHOTOGRAPH AND A COPY OF ANY APPLICABLE PROFESSIONAL LICENSE. ATTACH ADDITIONAL SHEETS, IF NECESSARY, TO PROVIDE REQUIRED INFORMATION. Page 3 of 4 F:\CLER\$ALL\aFORMS\BOARD AND COMMITTEES\8C APPLICATION REVISED 06142016.docx • i NAME: Erin Gaskin, MPH, JD DATE OF BIRTH: April 7, 1969 — Tampa, Florida CONTACT INFORMATION: Phone: 813-215-9799 Email: gaskinerin@gmail.com Linked In: LinkedIn: https://www.linkedin.com/in/erin-Baskin-mph-jd-23b1b45 Florida Bar Association Profile: www.floridabar.org/mybarprofile/180637 EDUCATION AND ADMISSIONS: UNIVERSITY OF FLORIDA, COLLEGE OF LAW Gainesville, Florida Degree: Juris Doctor (JD) — July 1999 Student Member: Health Law Society Law Clerk: McCarty, Helm, Keeter, Marion, Davis & O'Connor, LLP The Florida Bar Association — Admitted September 1999 - Health Law and Animal Law Sections The California Bar Association — Registered October 2012 — Eligible for In -House Counsel Certification under CA Rule 9.46 U.S. Court of Appeals, Eleventh Circuit — Admitted December 1999 U.S. District Court, Northern/Southern Districts of Florida — Admitted January 2000 U.S. District Court, Middle District of Florida — Admitted September 2000 UNIVERSITY OF SOUTH FLORIDA, COLLEGE OF PUBLIC HEALTH Tampa, Florida Degree: Master of Public Health (MPH) — May 1995 Coursework: Health Law; Epidemiology; Social & Behavioral Health; Environmental & Occupational Health; Public Health Policy, Finance & Management; and, Public Health Education & Program Planning Activities/Publications: Editor -in -Chief & Managing Editor - The Social Marketing Quarterly — An academic, peer-reviewed journal of public health research co-sponsored/funded by The Centers for Disease Control/USF College of Public Health; Student Member - The American Public Health Association. UNIVERSITY OF FLORIDA, COLLEGE OF JOURNALISM Gainesville, Florida Degree: Bachelor of Science (BS) — Telecommunications — 1992 Awards/Activities: The William Randolph Hearst Foundation National Journalism Award & Scholarship Recipient; The Florida Bar Association Award of Excellence for Media Coverage of Legal Issues; Student Government Senator Elect; Delta Gamma Fraternity and National Philanthropic Organization — benefitting sight conservation and aid to the blind. On -Air Training, Experience & Employment: Radio and Television News Anchor and Investigative Reporter for PBS, ABC and CBS Affiliate Stations in Gainesville, Lake City, Ocala and Jacksonville, Florida. EMPLOYMENT FOWLER WHITE BURNETT (Miami, Florida) Shareholder/Senior Law Partner - 2007 - present Complex health care and medical litigation including but not limited to the defense of medical schools, faculty, administrators, hospitals and physicians in professional liability, contract, regulatory, licensure and administrative disputes. Responsible for all aspects of litigation from inception through trial including but not limited to: client and witness preparation; expert retention/consultation; depositions/discovery; motion practice and hearings; and, mediation/trial. Also responsible for the management, supervision and training of legal interns, associate attorneys and staff as well as client retention/development. Representative clients include: The University of Miami Miller School of Medicine (medical clinics, hospitals, faculty, physicians and staff); HCA Healthcare Corporation/HCI (hospitals, physicians, practice groups and staff); Nova Southeastern University/Medical School (medical clinics, faculty and staff). OGDEN SULLIVAN (Tampa, Florida) Associate Attorney - 2003 — 2007 Complex multi-party litigation including but not limited to the defense of hospital liability and medical malpractice claims. Responsible for all aspects of litigation from inception through trial including: client and witness preparation; expert retention/consultation; depositions/discovery; motion practice and hearings; and, mediation/trial. Also responsible for the supervision and training of interns, associates and staff as well as client retention and development. Representative clients have included: HCA Healthcare Corporation/HCI (hospitals, physicians and staff); University Community Hospital System/University of South Florida Medical Faculty and Staff (hospital, medical faculty, physicians and staff). 2 PETERSON BERNARD (Fort Lauderdale, Florida) Associate Attorney -1999 - 2003 Complex multi-party litigation including but not limited to the defense of hospital liability, medical malpractice, dental malpractice, pharmacy malpractice, laboratory malpractice, nursing malpractice and legal malpractice claims. Responsible for all aspects of litigation from inception through trial including: client and witness preparation; expert retention/consultation; depositions/discovery; motion practice and hearings; and, mediation and settlement negotiations. Representative clients have included: CNA; Tenet Healthcare Corporation; North Broward Hospital District; St. Mary's Hospital; Good Samaritan Hospital; Florida Lawyers Mutual Insurance; FPIC (First Professional Insurance Company); Florida Medical Malpractice Joint Underwriting Association; Pro Assurance/Pro National Insurance Company; Zurich American Insurance. NORTHEASTERN TREATMENT CENTERS - 1996-1997 - Pennsylvania & Delaware Residential treatment of addictive diseases and other dual diagnosis disorders. Positions: Health Educator and Counselor II BEST START - 1993-1996 Tampa, FL Not-for-profit public health research corporation. Positions: Managing Editor & Editor -in -Chief of The Social Marketing Quarterly — An academic, peer-reviewed journal of public health research co-sponsored/funded by the Centers for Disease Control and the University of South Florida College of Public Health. Publications: Breast Cancer Screening: A Social Marketing Study, The Social Marketing Quarterly, Vol. III, No.1, p.24, Winter '96. CHARTER BEHAVIORAL HEALTH SYSTEM & HOSPITAL -1993-1996 - Tampa, Florida Acute, residential and out-patient psychiatric hospital services. Positions/Duties: Mental Health Counselor; Needs Assessment & Admissions Counselor; Crisis Intervention Counselor; Patient Educator; Health Care Marketing; Community Outreach; Group Facilitator; and, Staffing Coordinator. 3 MEMBERSHIPS, ACTIVITIES AND AWARDS • California Society for Healthcare Attorneys — 2016 • Presenter/Lecturer - 2014 Annual Meeting - Society of Vascular/Interventional Neurology • South Florida Legal Guide — Top Lawyers 2015 and 2016 — Medical Malpractice • South Florida Legal Guide Top Up and Comer - 2010 — 2014 — Medical Malpractice • Coral Gables Chamber of Commerce — 2012 to present • Dade County Bar Association - 2008 to present • Florida Association of Women Lawyers - Dade County - 2008 — present • 2008/09 Super Lawyers - "Rising Star" • Florida Bar Association — Health Law and Animal Law Sections —1999 — present • American Bar Association - Health Law and Litigation/Trial Sections —1999 to present • Council for Sustainable Florida — The Collins Center for Public Policy — Member • National Human Right Campaign (NHRC) — Member • University of Florida Alumni Association • William Randolph Hearst Foundation — Scholarship Recipient for Journalism —1991 • Florida Bar Association Award of Excellence in Journalism - Media Coverage of Legal Issues —1991 4 Fowler White Burnett, P.A. > Attorneys Page 1 of 2 Fowler White Burnett) (http://www.fowler-white.com/) ATTORNEYS AT LAW Traditional Values / Innovative Thinking Erin Gaskin SHAREHOLDER Miami 305.789.9219 egaskin(a�fowler-white.com (mailto: egaskin(ci)fowler-white.com ) Download vCard (/Portals/0/Attorneys/ Erin Gaskin.vcf ) As a civil litigator for 15 years, Erin Gaskin, a shareholder in the firm's Healthcare (http://www.fowler- white.com/Practices/HealthCare) Practice Group, has experience handling cases involving all forms of professional negligence, premises liability, products liability and bad faith claims on behalf of business entities and major insurance (http://www.fowler-white.com/Practices/FWB-Practices/Insurance) carriers. In addition to her legal education, Erin holds a Master's degree in public health and a Bachelor of Science degree in Journalism. Prior to practicing law, Erin worked as a mental health counselor/educator as well as the managing editor of an academic peer-reviewed journal of health research funded by the Centers for Disease Control. During her undergraduate training, Erin also worked as a health and science news reporter for various television stations in Florida. Erin's unique professional background, education and training provides her with valuable practical experience in the healthcare and medical fields as well as familiarity with the administrative functions of the entities delivering these services. Practice Focus Erin has substantial experience in handling multi-party complex litigation at every stage including mediation, arbitration and trial. She has successfully handled matters involving a diverse range of legal issues, including hospital liability, medical malpractice (http://www.fowler- white.com/Practices/MedicalMalpractice), legal malpractice, general liability and commercial liability arising from property, banking, trademark, construction and other contractual disputes. http://www.fowler-white.com/Attorneys/id/32 1/30/2017 Fowler White Burnett, P.A. > Attorneys Page 2 of 2 Currently, Erin is among the team of attorneys at Fowler White Burnett who represent the medical and healthcare industry including a major South Florida university medical school, an internationally renowned healthcare clinic, and one of the largest private hospital holding companies in the nation. As part of this team, Erin has contributed to the successful defense of complex multi-million dollar medical malpractice claims. Professional Associations and Memberships • The Florida Bar - Health Law Section, Animal Law Committee • Dade County Bar Association • Florida Association for Women Lawyers • University of Florida Alumni Association Speaking Engagements • Speaker, "The Physician As A Witness: The Interventional Neurologist As A Medical -Legal Expert," Society of Vascular and Interventional Neurology's (SVIN) Didactic Session, November 2014 © 2016 Fowler White Burnett, P.A. All Rights Reserved Fowler White Boggs, P.A. (http://www.fowlerwhite.com/) (no affiliation) Contact (/About-Us/Contact) Site Map (/SiteMap/) Terms of Use (/TermsofUse) DISCLAIMER. These materials have been prepared by Fowler White Burnett P.A. for informational purposes only and are not legal advice. This information is not intended to create, and receipt of it does not constitute, a lawyer -client relationship. Internet subscribers and online readers should not act upon this information without seeking professional counsel. Do not send us information until you speak with one of our lawyers and get authorization to send that information to us. http://www.fowler-white.com/Attorneys/id/32 1/30/2017 MIAMI - COUNTY SOURCE OF INCOME STATEMENT Section 2-11.1(i) of the County Ethics Code requires that certain employees and public officials file a financial disclosure Statement on a yearly basis by July 1st of every year. Disclosure for Tax Year Ending 2016 Last Name First Name Middle Name/Initial Mailing Address — Street Number Street Name, or P.O. Box City, State, Zip If your home address is your mailing address, and your home address is exempt from public records pursuant to Fla. Stat. §119.07, read instructions on the following page and check here. ❑ Filing as an Employee (check one) Filing as a Board Member (check one) 0 County .V] Municipal: (aw-Lt �Qm (Municipality) Board where serving L) m an l C0 .m Alternate address (if home addresfl is exempt) Work telephone Term began on/ended on List below every source of income you received, along with the address and the principal activity of each source. Include your public salary. Place the sources of income in descending order, with the largest source first. Examples of sources of income include: compensation for services, income from business, gains from property dealings, interest, rents, dividends, pensions, IRA distributions, and social security payments. Also, include any source of income received by another person for your benefit. However, the income of your spouse or any business partner need not be disclosed. If continued on a separate sheet, check here.❑ Name of Source of Income Address II County • Public Health Trust all Municipal: (Municipality) Department Position or Title Employee ID Number Work address Work telephone Employment began on/ended on Filing as a Board Member (check one) 0 County .V] Municipal: (aw-Lt �Qm (Municipality) Board where serving L) m an l C0 .m Alternate address (if home addresfl is exempt) Work telephone Term began on/ended on List below every source of income you received, along with the address and the principal activity of each source. Include your public salary. Place the sources of income in descending order, with the largest source first. Examples of sources of income include: compensation for services, income from business, gains from property dealings, interest, rents, dividends, pensions, IRA distributions, and social security payments. Also, include any source of income received by another person for your benefit. However, the income of your spouse or any business partner need not be disclosed. If continued on a separate sheet, check here.❑ Name of Source of Income Address Description of the Principal Business Activity 0 w Wk4. 4 nd-( 11 r 13r ukz-/ I FL -AA 402>Y1# roa' t i/ Am.h6 %d e PL --- L33/33 33 /3 1 I hereby wear (or affir ' that the information above is a true and correct statement. Signature son 1' irrg 36 - ) Date signed RECEIVED BY ELECTIONS DEPARTMENT: ❑ Hardcopy ❑ Electronic Copy OFFICE USE ONLY Accepted: Y / N Deficiency: Processed Date/Initials: 138 SP -14 COE 2016 Scanned Date/Initials: til Li L..! City of Miami Beach 1700 Convention Center Drive, Miami Beach, Florida 33139, www.miamibeachfl.gov CITY CLERK'S OFFICE Telephone: 305.673.7411 Fax: 305.673.7254 CityClerk@miamibeachfl.gov Acknowledgement of fines/suspension for Board/Committee Members for failure to comply with Miami - Dade County Financial Disclosure Code Provision Code Section 2-11.1(i) (2) Board Member's Name: e�H CM6(41 h I understand that no later than July 1, of each year all members of Boards and Committees of the City of Miami Beach, including those of a purely advisory nature, are required to comply with Miami -Dade County Financial Disclosure Requirements. This means that the members of City Advisory Boards, whose sole or primary responsibility is to recommend legislation or give advice to the City Commission, must file, even though they may have been recently appointed. One of the following forms must be filed with the City Clerk of Miami Beach, 1700 Convention Center Drive, Miami Beach, Florida, no later than 12:00 noon of July 1, of each year. 1. A `Source of Income Statement" 2. A "Statement of Financial Interests (Form 1)" 3. A Copy of your latest Federal Income Tax Return Failure to file one of thes forms, pursuant to the Miami -Dade County Code, may subject the person to a fine of no more than $500, 61/.ays in jail or both. 1-36-)7 Signatu - J Date Updated: Monday, April 20, 2015 Page 4 of 4 F\CLER\SALL\aFORMS\BOARD AND COMMITTEES \SC APPLICATION REVISED 06022014.docx AA*Mi BEACH Name: DIVERSITY STATISTICS REPORTING C4' Board / Committee: (4 0 WO le) 1'7 S • .e_ 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 i Female Race/Ethnic Categories What is your race? African-American/Black 8 Caucasian/White Asian or Pacific islander LJ Native-American/American Indian LJ Other — Print Race: Do you consider yourself to be Spanish, Hispanic or Latino/a? Mark the "No" box not Spanish, Hispanic, Latinc/a. No Yes Do you consider yourself Physically Disabled? No Ea Yes CAUsers\CENTFraN'AppData\Locar,Microsoft\Windows\Ternoorary Internet FiIes\Content.Outlook\NP4J9CNx1,80 minorily information form 05-20-13 FINAL.doc Upda.ted: Monday, January 26, 2015