Western Australian Consolidated Regulations

GENDER REASSIGNMENT REGULATIONS 2001 - SCHEDULE 1

[r. 4]

Form 1

APPLICATION FOR RECOGNITION CERTIFICATE FOR AN ADULT

IMPORTANT NOTICE

Information provided in this application will be treated CONFIDENTIALLY

Personal details of applicant

Full name
Address
Date of birth
Place of birth
Full names of applicant’s parents

Reassignment procedure

I have undergone a reassignment procedure from —             (a)         male to female             (b)         female to male

[ ] [ ] Tick the appropriate box and attach a statement signed by a medical practitioner that the person has undergone the reassignment procedure.

Compliance with section 15 of the Gender Reassignment Act 2000

The reassignment procedure was carried out in this State. My birth was registered in this State.	[ ] [ ]
I am a resident of this State and have been a resident of this State for not less than 12 months.	[ ] Tick the appropriate box or boxes and attach a certified copy of your birth certificate and any other relevant documents, such as —                   (i)         documents relating to where the reassignment procedure was carried out;                   (ii)         the original, or certified copies, of any documents showing proof of residency and length of residency.
I believe that my true gender is the gender to which I have been reassigned, as specified in this form.	[ ] Tick box if correct.
I have adopted the lifestyle and have the gender characteristics of a person of the gender to which I have been reassigned, as specified in this form.	[ ] Tick box if correct. You may wish to attach any information you consider relevant.
I have received counselling in relation to my gender identity.	[ ] Tick box if correct. Please specify details of counselling and attach a statement from the person who provided the counselling.
I am married. I am not married.	[ ] [ ] Tick the appropriate box. A recognition certificate cannot be issued to a person who is married.

Hearing of application

I wish to attend the hearing of this application. I do not wish to attend the hearing of this application. I wish to appear at the hearing of this application and to make submissions to the Board.

[ ] [ ] [ ] Tick the appropriate box or boxes.

Declaration by applicant

I declare that to the best of my knowledge no statement made in this application is false, or misleading in any material respect. Signature         Date         Name of person signing         NOTE: Section 23 of the Gender Reassignment Act 2000 provides that it is an offence for a person to make a statement knowing it to be false or misleading in a material respect for the purposes of, or in connection with, an application. Penalty: $2 000.

        [Form 1 amended in Gazette 14 May 2004 p. 1447.]

Form 2

APPLICATION FOR RECOGNITION CERTIFICATE FOR A CHILD

IMPORTANT NOTICE

Information provided in this application will be treated CONFIDENTIALLY

Personal details of the child the application relates to

Full name of child
Address of child
Date of birth
Place of birth
Full names of child’s parents

Personal details of the person making the application

Name of person making the application
Address of person making the application
Relationship of person to the child	This application must be made by the child’s guardian.

Reassignment procedure

The child this application relates to has undergone a reassignment procedure from —             (a)         male to female         (b)         female to male

[ ] [ ] Tick the appropriate box and attach a statement signed by a medical practitioner that the child has undergone the reassignment procedure.

Compliance with section 15 of the Gender Reassignment Act 2000

The reassignment procedure was carried out in this State. The child’s birth was registered in this State. The child is a resident of this State and has been a resident of this State for not less than 12 months.	[ ] [ ] [ ] Tick the appropriate box or boxes and attach a certified copy of the child’s birth certificate and any other relevant documents, such as —                   (i)         documents relating to where the reassignment procedure was carried out;                   (ii)         the original, or certified copies, of any documents showing proof of residency and length of residency.
These are the reasons that I believe that it is in the best interests of the child that a recognition certificate is issued in respect of the child.
The child is married. The child is not married.	[ ] [ ] Tick the appropriate box. A recognition certificate cannot be issued to a person who is married.

Hearing of application

I wish to, or the child wishes to, attend the hearing of this application. I do not wish to, or the child does not wish to, attend the hearing of this application. I wish to, or the child wishes to, appear at the hearing of this application and to make submissions to the Board.

[ ] [ ] [ ] Tick the appropriate box or boxes.

Declaration by applicant

I declare that to the best of my knowledge no statement made in this application is false, or misleading in any material respect. Signature         Date         Name of person signing         NOTE: Section 23 of the Gender Reassignment Act 2000 provides that it is an offence for a person to make a statement knowing it to be false or misleading in a material respect for the purposes of, or in connection with, an application. Penalty: $2 000 or imprisonment for 6 months.

        [Form 2 amended in Gazette 25 Oct 2002 p. 5309.]