Form Dld-136 - Medical Certification And Authorization
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1Reno/Sparks/Carson City (775) 684-4DMV (4368)
Las Vegas Area (702) 486-4DMV (4368)
Rural Nevada or Outside Nevada (877) 368-7828
Website:
MEDICAL CERTIFICATION AND AUTHORIZATION
(GENDER CHANGE)
NAC 483.070
SECTION 1 – CERTIFICATION AND AUTHORIZATION – TO BE COMPLETED BY APPLICANT
Nevada Driver License or Identification Card Number _____________________________Date of Birth ____________
Applicant’s Name________________________________________________________________________________
Last
First
Middle
Mailing Address _________________________________________________________________________________
Primary Physical Address _________________________________________________________________________
Phone Number (Optional) ________________________Email Address (Option_______________________________
All records of the Nevada Department of Motor Vehicles, relating to the physical or mental condition of any person are
confidential and not open to public inspection. I hereby authorize my physician, to release the information below to the
Nevada Department of Motor Vehicles for the purposes of obtaining a driver license or an identification card under my
identified gender. I hereby certify, under penalty of perjury, that all statements in this application are true and correct.
Applicant’s
Signature______________________________________________________________Date_____________________
SECTION 2 – TO BE COMPLETED BY A PHYSICIAN OR AN OSTEOPATHIC PHYSICIAN LICENSED IN THE
UNITED STATES (NAC 483.070)
As a Physician for the above-named patient, I hereby certify that the applicant:
Is undergoing treatment and living full-time as the following identified gender : ____ Male ____ Female
Please print or type and complete in full:
Physician’s Name________________________________________________________________________________
First
Middle
Last
Physician’s License No. __________________________________________________________________________
Mailing Address _________________________________________________________________________________
City
State
Zip Code
Phone Number (Optional) ________________________Email Address (Option) ______________________________
Physician’s Signature _____________________________________________________ Date ___________________
DLD-136
(Revised 7/28/2017)
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