Mv2020 - Request For Gender Change On Driver License/identification Card

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REQUEST FOR GENDER CHANGE ON

DRIVER LICENSE/IDENTIFICATION CARD

PLEASE TYPE OR PRINT ALL INFORMATION IN BLUE OR BLACK INK

Customer: Please complete Sections A, B, C, and D.

A - DRIVER INFORMATION

DRIVER LICENSE NUMBER

LAST NAME(S)

SUFFIX

FIRST NAME

MIDDLE NAME

DATE OF BIRTH

DAYTIME TELEPHONE NUMBER

E-MAIL ADDRESS (if applicable)

MONTH

DAY

YEAR

Please check the product(s) you currently have:

Class D Driver License

Commercial Driver License

Identification Card

B - GENDER DESIGNATION STATEMENT

, wish the gender designation on my driver license/ID card to read:

(Applicant’s Full Name)

MALE

FEMALE

C - TO BE COMPLETED BY MEDICAL OR SOCIAL SERVICE PROVIDER LICENSED IN THE UNITED STATES

PROVIDER’S LAST NAME

PROVIDER’S FIRST NAME

PROVIDER’S TITLE

PROVIDER’S ORGANIZATION

STATE MEDICAL LICENSE #

STATE LICENSED IN

PROVIDER’S STREET ADDRESS

CITY

STATE

ZIP

I am a licensed:

Physician

Therapist/Counselor

Social Worker

My practice includes assisting, counseling or treating persons with gender identity issues, including the applicant named herein, and in my

professional opinion, the applicant’s gender identity is . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Male

Female

and can reasonably be expected to continue as such for the foreseeable future.

I certify, under the penalty of perjury, that the foregoing medical or social service provider information on this application is true and correct.

PROVIDER’S SIGNATURE: ____________________________________________________________________ DATE: ____________________

D - AUTHORIZATION AND CERTIFICATION

I certify, under the penalty of perjury, that the information on this application is true and correct to the best of my knowledge, that this request for the

selected gender designation to appear on my driver license/ID card accurately reflects my gender identity and is not for any fraudulent or other

unlawful purpose, and that I am a bona fide resident of Delaware.

APPLICANT’S SIGNATURE: ____________________________________________________________________ DATE: ____________________

E – TO BE COMPLETED BY THE DIVISION OF MOTOR VEHICLES

APPROVING SUPERVISOR/SENIOR NAME: ________________________________________________________________________________

APPROVING SUPERVISOR/SENIOR SIGNATURE: __________________________________________________ DATE: ___________________

MV2020

08/11