Form B-372 "Gender Designation Change Form" - Connecticut

What Is Form B-372?

This is a legal form that was released by the Connecticut Department of Motor Vehicles - a government authority operating within Connecticut. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on April 1, 2017;
  • The latest edition provided by the Connecticut Department of Motor Vehicles;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form B-372 by clicking the link below or browse more documents and templates provided by the Connecticut Department of Motor Vehicles.

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Download Form B-372 "Gender Designation Change Form" - Connecticut

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GENDER DESIGNATION
STATE OF CONNECTICUT
DEPARTMENT OF MOTOR VEHICLES
CHANGE FORM
On The Web At ct.gov/dmv
B-372 Rev. 4-2017
The DMV can only accept original forms with original signatures. Photocopies and faxes are not acceptable.
You must surrender the existing driver’s license or ID Card that is to be amended.
PART 1: TO BE COMPLETED BY APPLICANT (Name on current Driver’s License/ID or Identity documents)
LAST NAME
FIRST NAME
MIDDLE
SOCIAL SECURITY NUMBER
ZIP CODE
DRIVER'S LICENSE/ID NUMBER
STREET ADDRESS
CITY/TOWN
Gender Designation Statement:
I,
wish the gender designation on my
(print name from above)
:
Driver’s License/ID Card to read (circle one)
MALE
FEMALE
I hereby swear, under the penalty of perjury, that this request for the selected gender designation to appear
on my Driver’s License/ID Card is for the purpose of ensuring that my Driver’s License/ID Card accurately
reflects my gender identity and is not for any fraudulent or other unlawful purpose.
SIGNATURE
DATE
X
The information provided to the Commissioner of Motor Vehicles herein is subscribed by me, under penalty of false statement,
in accordance with the provisions of Section 14-110 and 53a-157b of the Connecticut General Statutes.
PART 2: TO BE COMPLETED BY MEDICAL OR SOCIAL SERVICE PROVIDER
LAST NAME
FIRST NAME
TITLE
PROVIDER'S ORGANIZATIONAL NAME (If applicable)
PROVIDER'S STREET ADDRESS
CITY
STATE
ZIP CODE
PROVIDER'S TELEPHONE NUMBER
PROVIDER'S E-MAIL
PROVIDER'S PROFESSIONAL LICENSE NUMBER AND STATE
I am licensed as a:
THERAPIST OR COUNSELOR
PSYCHIATRIC SOCIAL WORKER
PHYSICIAN
PHYSICIAN ASSISTANT
ADVANCED PRACTICE REGISTERED NURSE
My practice includes the treatment and counseling of persons with gender identity issues, including the applicant
named herein, and in my professional opinion, the applicant’s gender identity is (circle one):
MALE
FEMALE
and can reasonably be expected to continue as such for the foreseeable future.
I hereby certify, under the penalty of perjury, that the foregoing information is true and correct.
SIGNATURE
DATE
X
The information provided to the Commissioner of Motor Vehicles herein is subscribed by me, under penalty of false statement,
in accordance with the provisions of Section 14-110 and 53a-157b of the Connecticut General Statutes.
GENDER DESIGNATION
STATE OF CONNECTICUT
DEPARTMENT OF MOTOR VEHICLES
CHANGE FORM
On The Web At ct.gov/dmv
B-372 Rev. 4-2017
The DMV can only accept original forms with original signatures. Photocopies and faxes are not acceptable.
You must surrender the existing driver’s license or ID Card that is to be amended.
PART 1: TO BE COMPLETED BY APPLICANT (Name on current Driver’s License/ID or Identity documents)
LAST NAME
FIRST NAME
MIDDLE
SOCIAL SECURITY NUMBER
ZIP CODE
DRIVER'S LICENSE/ID NUMBER
STREET ADDRESS
CITY/TOWN
Gender Designation Statement:
I,
wish the gender designation on my
(print name from above)
:
Driver’s License/ID Card to read (circle one)
MALE
FEMALE
I hereby swear, under the penalty of perjury, that this request for the selected gender designation to appear
on my Driver’s License/ID Card is for the purpose of ensuring that my Driver’s License/ID Card accurately
reflects my gender identity and is not for any fraudulent or other unlawful purpose.
SIGNATURE
DATE
X
The information provided to the Commissioner of Motor Vehicles herein is subscribed by me, under penalty of false statement,
in accordance with the provisions of Section 14-110 and 53a-157b of the Connecticut General Statutes.
PART 2: TO BE COMPLETED BY MEDICAL OR SOCIAL SERVICE PROVIDER
LAST NAME
FIRST NAME
TITLE
PROVIDER'S ORGANIZATIONAL NAME (If applicable)
PROVIDER'S STREET ADDRESS
CITY
STATE
ZIP CODE
PROVIDER'S TELEPHONE NUMBER
PROVIDER'S E-MAIL
PROVIDER'S PROFESSIONAL LICENSE NUMBER AND STATE
I am licensed as a:
THERAPIST OR COUNSELOR
PSYCHIATRIC SOCIAL WORKER
PHYSICIAN
PHYSICIAN ASSISTANT
ADVANCED PRACTICE REGISTERED NURSE
My practice includes the treatment and counseling of persons with gender identity issues, including the applicant
named herein, and in my professional opinion, the applicant’s gender identity is (circle one):
MALE
FEMALE
and can reasonably be expected to continue as such for the foreseeable future.
I hereby certify, under the penalty of perjury, that the foregoing information is true and correct.
SIGNATURE
DATE
X
The information provided to the Commissioner of Motor Vehicles herein is subscribed by me, under penalty of false statement,
in accordance with the provisions of Section 14-110 and 53a-157b of the Connecticut General Statutes.