Gender Designation On A License Or Identification Card Form
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1STATE OF RHODE ISLAND AND PROVIDENCE PLANTATIONS
DIVISION OF MOTOR VEHICLES
LICENSE AND REGISTRATION OFFICE
600 New London Avenue
Cranston, RI 02920-3024
Phone: 401-462-4368
Fax: 401-462-5785/5786
GENDER DESIGNATION ON A LICENSE OR IDENTIFICATION CARD
Procedure for Changing Designation on Driver’s License or Identification Card
Applicants requesting a change of the gender designation on their driver’s license or identification card from that showing on their identity proof documents
must:
Surrender any current state-issued license or identification card;
Submit a completed Gender Designation form; and
Pay applicable fees for new or updated license or identification card. The applicant shall have a new photograph taken.
Employees shall not request additional gender-related information beyond that required on the applicable forms or otherwise inquire about the applicant’s
private medical history or records.
The Gender Designation Form contains private medical information and will be kept confidential and protected under the provisions of the
Driver Privacy and
Protection
Act.
Name Change
Name changes related to gender are completed via submission of appropriate court documents and also must be reflected on the
Social Security
card.
Please refer to the
RI DMV Document Checklist - License and ID
Cards.
PART ONE: TO BE COMPLETED BY APPLICANT
_________________________________________________________________
____________________________________
Last Name
First Name
Middle Initial
Social Security Number
_____________________________________________________________________________________
_____________________________
Street Address
City/Town
State
Zip Code
License/Identification Number
I, ______________________________, wish the designation of gender on my driver’s license or identification card to read (please
check one):
Male
Female
I, the undersigned, hereby make application for either license, state identification card or permit and declare under penalty of
perjury that all statements made on this application are true and complete to the best of my knowledge and belief.
Signature: ______________________________
Date: _________________
PART TWO: TO BE COMPLETED BY MEDICAL OR SOCIAL SERVICE AUTHORITY
_______________________________________________________________________________________________________________
Provider Last Name
Provider First Name
Provider Title
_________________________________________________________________________________________________________________
Provider Organization Name (if applicable)
_____________________________________________________________________________________
_____________________________
Provider Street Address
City/Town
State
Zip Code
Provider Telephone
______________________________________________
______________________________________________
Provider E-Mail
Provider Organization or Professional License Number
I am a:
Physician
Licensed therapist or counselor
Case worker or social worker
In my professional opinion, the applicant’s gender identity is (please check one):
Male
Female
and can reasonably be
expected to continue as such in the foreseeable future.
I, the undersigned, hereby declare under penalty of perjury that all statements made in this section, “Part Two,” by me, are true
and complete to the best of my knowledge and belief.
Signature: ______________________________
Date: _________________
rev. 05/12
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