This document is a change of gender designation form for a driver's license or identification card. It has two parts: part one is completed by the applicant to request a change of their gender marker, and part two is completed and signed by a medical or social service professional to confirm the applicant's gender identity.

1. CHANGE OF GENDER
DESIGNATION FORM
PROVIDER ORGANIZATION NAME (if applicable)
PROVIDER ORGANIZATION or PROFESSIONAL LICENSE NUMBERPROVIDER E-MAILPROVIDER PHONE NUMBER
ZIP CODESTATECITYPROVIDER STREET ADDRESS
PROVIDER TITLEPROVIDER FIRST NAMEPROVIDER LAST NAME (please print)
PART TWO: TO BE COMPLETED BY MEDICAL OR SOCIAL SERVICE AUTHORITY
PART ONE: TO BE COMPLETED BY APPLICANT
LAST NAME (please print) FIRST NAME MIDDLE NAME
STREET ADDRESS CITY STATE ZIP CODE
ODL/ID CUSTOMER #
I, _________________________________________ wish to change the gender designation on my
driver license or identification card to read (check one): Male Female
I hereby certify under penalty of law that this request for gender designation change is for the
purpose of ensuring my driver license / identification card accurately reflects my gender identity and
is not for any fraudulent or other unlawful purpose.
I am a:
Physician
Licensed therapist or counselor
Case worker or social worker
In my professional opinion, the applicant's gender identity is (check one): Male Female
and can reasonably be expected to continue as such in the foreseeable future.
I hereby certify under penalty of law the foregoing information is true and correct.
SIGNATURE OF MEDICAL or SOCIAL SERVICE AUTHORITY
DATE SIGNED
X
APPLICANT SIGNATURE
X
DATE SIGNED
735-7401 (12-14)
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