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Fillable Printable Change Of Gender Designation Request

Fillable Printable Change Of Gender Designation Request

Change Of Gender Designation Request

Change Of Gender Designation Request

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Change of Gender Designation Request
Use this form to request a gender designation change on your Washington driver license, instruction permit, identification
(ID) card, enhanced driver license, or enhanced ID card.
Complete the Applicant section and have the medical provider or social service worker familiar with your treatment
complete the Medical or social service provider section.
To speed up processing, take this completed form with your Washington driver license, instruction permit, ID card,
enhanced driver license, or enhanced ID card to any driver licensing office. Or mail this form and a photocopy of your
license, permit, or ID card to:
Programs and Services, Record Response
Department of Licensing
PO Box 9030
Olympia WA 98507-9030
If mailed in, we will notify you when your request has been processed.
Incomplete requests will not be processed.
Applicant
TYPE or PRINT Name as it appears on your current driver license or ID card (Last, First, Middle) Driver license or ID card number
(Area code) Daytime telephone number Email If request is mailed, notify me by
Email U.S. mail
Answer the following
What gender designation would you like on your driver license or ID card? .................... Male Female
I authorize the licensed medical provider below to release information related to this request.
Applicant signature
Medical or social service provider
ONLY a licensed physician, psychiatrist, psychologist, naturopath, advanced registered nurse practitioner, physician
assistant, certified osteopathic physician assistant, or social service worker familiar with your treatment may complete this
section.
Provider name as it appears on your license Title
Professional license number Expiration date Issuing state/jurisdiction
Hospital or clinic name
(Area code) Telephone number Email
Answer the following
What is the gender identification of this applicant? ....................................... Male Female
I certify under penalty of perjury under the laws of the state of Washington that the foregoing is true and correct.
Date and place (city or county) signed Provider signature
DLE-520-043 (R/1/17)WA
Click here to START or CLEAR, then hit the TAB button
Print completed form and applicant signs here.
Provider signs here.
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