Form 735-7401 - Change Of Gender Designation Form
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CHANGE OF GENDER
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DESIGNATION FORM
PART ONE:
TO BE COMPLETED BY APPLICANT
LAST NAME (please print)
FIRST NAME
MIDDLE NAME
ODL/ID CUSTOMER #
STREET ADDRESS
CITY
STATE
ZIP CODE
I, _________________________________________ wish to change the gender designation on my
Male
Female
driver license or identification card to read (check one):
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.
APPLICANT SIGNATURE
DATE SIGNED
X
PART TWO:
TO BE COMPLETED BY A LICENSED HEALTH CARE PROVIDER or SOCIAL SERVICE AUTHORITY
PROVIDER LAST NAME (please print)
PROVIDER FIRST NAME
PROVIDER TITLE
PROVIDER ORGANIZATION NAME (if applicable)
PROVIDER STREET ADDRESS
CITY
STATE
ZIP CODE
PROVIDER ORGANIZATION or PROFESSIONAL LICENSE NUMBER
PROVIDER PHONE NUMBER
PROVIDER E-MAIL
I am a:
Primary Care Provider (PCP) (Physician, Nurse Practitioner (NP) or Physician Assistant (PA))
Clinical Social Worker, Surgeon, or a Doctor of Naturopathic Medicine
Licensed Professional Counselor or Therapist
Licensed Psychologist
Social Service Case Specialist, Worker, or other Social Service Authority
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.
DATE SIGNED
SIGNATURE OF HEALTH CARE PROVIDER or SOCIAL SERVICE AUTHORITY
X
735-7401 (10-15)
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