Form BMV2369 "Declaration of Gender Change" - Ohio

What Is Form BMV2369?

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

Form Details:

  • Released on September 1, 2019;
  • The latest edition provided by the Ohio Department of Public Safety;
  • 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 printable version of Form BMV2369 by clicking the link below or browse more documents and templates provided by the Ohio Department of Public Safety.

ADVERTISEMENT
ADVERTISEMENT

Download Form BMV2369 "Declaration of Gender Change" - Ohio

Download PDF

Fill PDF online

Rate (4.3 / 5) 17 votes
OHIO DEPARTMENT OF PUBLIC SAFETY
BUREAU OF MOTOR VEHICLES
DECLARATION OF GENDER CHANGE
INSTRUCTIONS
The purpose of this form is to allow an individual, under the guidance and direction of a qualified and licensed professional,
to change their gender designation.
All records of the Ohio Department of Public Safety or Bureau of Motor Vehicles relating to the physical or mental condition
of any person are confidential and are not open to public record.
Send completed form to:
Ohio Department of Public Safety
Bureau of Motor Vehicles
Attn: License Control
P.O. Box 16784
Columbus, Ohio 43216-6784
Phone: (844) 644-6268
Fax:
(614) 752-7306
Please allow 7 - 10 days for processing. The applicant will be notified in writing if the gender change is approved, and will
receive documentation that may be presented to any local License Bureau agency.
BMV 2369 9/19 [760-1491] Page 1 of 2
OHIO DEPARTMENT OF PUBLIC SAFETY
BUREAU OF MOTOR VEHICLES
DECLARATION OF GENDER CHANGE
INSTRUCTIONS
The purpose of this form is to allow an individual, under the guidance and direction of a qualified and licensed professional,
to change their gender designation.
All records of the Ohio Department of Public Safety or Bureau of Motor Vehicles relating to the physical or mental condition
of any person are confidential and are not open to public record.
Send completed form to:
Ohio Department of Public Safety
Bureau of Motor Vehicles
Attn: License Control
P.O. Box 16784
Columbus, Ohio 43216-6784
Phone: (844) 644-6268
Fax:
(614) 752-7306
Please allow 7 - 10 days for processing. The applicant will be notified in writing if the gender change is approved, and will
receive documentation that may be presented to any local License Bureau agency.
BMV 2369 9/19 [760-1491] Page 1 of 2
OHIO DEPARTMENT OF PUBLIC SAFETY
BUREAU OF MOTOR VEHICLES
DECLARATION OF GENDER CHANGE
TO BE COMPLETED BY APPLICANT (Please type or print in ink.)
APPLICANT’S LEGAL LAST NAME
FIRST NAME
MI
RESIDENTIAL ADDRESS
CITY
STATE
ZIP CODE
DRIVER LICENSE OR ID NUMBER
DATE OF BIRTH
TELEPHONE NUMBER
MY GENDER IDENTITY IS
(
)
-
MALE
FEMALE
I certify that this request for gender designation is for the purposes of ensuring my driver’s license/identification card
accurately reflects my gender identity and is not for any fraudulent or other unlawful purpose. I certify under penalty of
perjury that all information on this form is true and correct.
APPLICANT’S SIGNATURE
DATE SIGNED
X
RELEASE OF INFORMATION
I hereby authorize my licensed professional to release the information below to the Ohio Bureau of Motor Vehicles for the
(Applicant’s Initials)
purposes of obtaining a driver license or an identification card under my identified gender.
LICENSED PROFESSIONAL’S STATEMENT
To be completed by a physician, psychologist, therapist, nurse practitioner, or social worker who is licensed to practice in
the United States that certifies the gender identity of the applicant.
PHYSICIAN
NURSE PRACTITIONER
PSYCHOLOGIST
THERAPIST
SOCIAL WORKER
LICENSED PROFESSIONAL’S LAST NAME
FIRST NAME
TELEPHONE NUMBER
(
)
-
PROFESSIONAL LICENSE / CERTIFICATE NUMBER
ISSUING STATE
NAME OF HOSPITAL OR MEDICAL CLINIC
STREET ADDRESS
CITY
STATE
ZIP CODE
MY PROFESSIONAL OPINION IS THAT THE APPLICANT’S GENDER IDENTITY IS
MALE
FEMALE
I certify that my practice includes the treatment and counseling of persons with gender identity concerns, including the
applicant named above, who is my patient. I certify under the penalty of perjury that all information on this form is true and correct.
SIGNATURE OF LICENSED PROFESSIONAL
DATE SIGNED
X
BMV 2369 9/19 [760-1491] Page 2 of 2
Page of 2