Page _____ of _____
Florida Department of State
Minority Appointment Reporting Form for Calendar Year 2018
(Section 760.80, Florida Statutes – Form due NLT December 1, 2019)
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 12/31/18, 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 12/31/18”.)
Race
Authority*
Membership
%
Gender
Authority*
Membership
%
Total _____
Disability
Appointed by
Authority*
in 2018, only
Total Disability
Membership
as of 12/31/18
%
Physically
Disabled
_____
_____
_____
Total _____
*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 12/31/18, 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 12/31/18”.)
Race
Authority*
Membership
%
Gender
Authority*
Membership
%
Total _____
Disability
Appointed by
Authority*
in 2018, only
Total Disability
Membership
as of 12/31/18
%
Physically
Disabled
_____
_____
_____
Total _____
*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. 08/2019)
