Form Ds-De 143 - Minority Appointment Reporting Form - 2014
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1Page _____ of _____
Florida Department of State
Minority Appointment Reporting Form for Calendar Year 2014
(Section 760.80, Florida Statutes – Form due NLT December 1, 2015)
Appointing Authority:* ________________________________________________________________________
Contact Person: ______________________________
Address: _________________________________
Phone: __________________________
City/State/Zip: _________________________________
Entity
: ______________________________________________
(Name of Board, Commission, Council, or Committee)
Does this entity have multiple appointing authorities?
Yes
No
The entity’s total membership as of 12/31/14, regardless of appointing authority: _______________________
(Note: This figure is the denominator to be used in calculating percentages below; the numerator for calculating the
percentages is the number in the second column, i.e., “Total membership as of 12/31/14”.)
Appointed by
Total Race
Appointed
Total Gender
Race
Gender
Authority* in
Membership
%
by Authority*
Membership as
%
2014, only
as of 12/31/14
in 2014, only
of 12/31/14
African-American
_____
_____
_____
Male
_____
_____
_____
Asian-American
_____
_____
_____
Female
_____
_____
_____
Hispanic-American
_____
_____
_____
Not Known
_____
_____
_____
Total
_____
Native-American
_____
_____
_____
Appointed by
Total Disability
Caucasian
_____
_____
_____
Disability
Authority*
Membership
%
in 2014, only
as of 12/31/14
Not Known
_____
_____
_____
Physically
____
____
____
Total
_____
Disabled
*Figures are to reflect appointments made only by this Appointing Authority. Please complete all sections.
Entity
: ______________________________________________
(Name of Board, Commission, Council, or Committee)
Does this entity have multiple appointing authorities?
Yes
No
The entity’s total membership as of 12/31/14, regardless of appointing authority: _______________________
(Note: This figure is the denominator to be used in calculating percentages below; the numerator for calculating the
percentages is the number in the second column, i.e., “Total membership as of 12/31/14”.)
Appointed by
Total Race
Appointed
Total Gender
Race
Gender
Authority* in
Membership
%
by Authority*
Membership as
%
2014, only
as of 12/31/14
in 2014, only
of 12/31/14
African-American
_____
_____
_____
Male
_____
_____
_____
Asian-American
_____
_____
_____
Female
_____
_____
_____
Hispanic-American
_____
_____
_____
Not Known
_____
_____
_____
Total
_____
Native-American
_____
_____
_____
Appointed by
Total Disability
Caucasian
_____
_____
_____
Disability
Authority*
Membership
%
in 2014, only
as of 12/31/14
Not Known
_____
_____
_____
Physically
____
____
____
Total
_____
Disabled
*Figures are to reflect appointments made only by this Appointing Authority. Please complete all sections.
Return to:
Department of State, The R. A. Gray Building, Room 316, 500 South Bronough Street, Tallahassee, FL 32399-0250
DS-DE 143 (rev. 5/2015)
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