CHANGE OF GENDERDESIGNATION 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 APPLICANTLAST 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 FemaleI 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:PhysicianLicensed therapist or counselorCase 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

XAPPLICANT SIGNATURE

XDATE SIGNED

735-7401 (12-14)