Tattoo Tech: Training/Experience Verification

Public Health: Tattoo Technician Training Verification

DPH Data Management and Governance (PLIS)
This form is intended to verify two thousand hours of training. It must be completed by the Connecticut licensed tattoo technician who supervised the trainee and returned directly to this office in support of licensure.
This is to verify that
Name

First NameLast Name
Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Was under my direct and personal supervision FROMDate* TO Date* for hours* hours per week and completed a minimum of two thousand hours of supervised training.
Under penalty of perjury, I confirm that I am the licensed tattoo technician supervising training and that the above information is true and accurate.
Signature:
Date:

MonthDayYear
Printed name:
Connecticut Department of Public Health
Tattoo Licensing
410 Capitol Ave., MS #12 APP
P.O. Box 340308
Hartford, CT 06134
Fax: (860) 707-1931
dph.healingarts@ct.gov
Should be Empty:

Public Health: Tattoo Technician Training Verification