Fillable Printable Form 5532 - Gender Designation Change Request Form
Fillable Printable Form 5532 - Gender Designation Change Request Form
Form 5532 - Gender Designation Change Request Form
Gender Designation Statement Applicant Information
Form
5532
Missouri Department of Revenue
Gender Designation Change Request Form
Driver License Bureau
Form 5532 (Revised 11-2016)
Visit http://dor.mo.gov/
for additional information.
Last Name First Middle
Date of Birth (MM/DD/YYYY) Social Security Number
___ ___ /___ ___ /___ ___ ___ ___
Mailing Address
City State ZIP Code
I ____________________________________________________________ (print) request the gender designation on my
instruction permit, driver license, or nondriver license to read (Select One) Male Female
I hereby swear, under the penalty of perjury, that this request to change the gender designation on my instruction
permit, driver license, or nondriver license is for the purpose of accurately reflecting my gender identity and is not
for any fraudulent or other unlawful purpose.
Applicant’s Signature _____________________________________ Printed Name _____________________________________
Date (MM/DD/YYYY)
___ ___ /___ ___ /___ ___ ___ ___
Medical or Social Service Provider
Provider Signature Provider Printed Name Date (MM/DD/YYYY)
___ ___ /___ ___ /___ ___ ___ ___
Office Mailing Address
City State ZIP Code
I am a licensed:
Provider Organization or Professional License Number and State
Phone Number Fax Number
(___ ___ ___)___ ___ ___-___ ___ ___ ___ (___ ___ ___)___ ___ ___-___ ___ ___ ___
Are you a medical or social service provider for this patient? Yes No
In my professional opinion, the applicant’s gender identity is (Select One) Male Female
and can reasonably be expected to continue as such in the foreseeable future.
I hereby certify, under the penalty of perjury that the foregoing information is true and correct.
Provider’s Signature _____________________________________ Printed Name _____________________________________
Date (MM/DD/YYYY)
___ ___ /___ ___ /___ ___ ___ ___
Physician Therapist or Counselor Social Worker
Other (please describe) ______________________________________________________________________________
This form must be completed and taken to a license ofce for processing.
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