Tattoo Tech: Out-of-state Practice Verification

Public Health: Tattoo Practice Affidavit

DPH Data Management and Governance (PLIS)
Please note that this form must be notarized.
Pursuant to Connecticut General Statutes Sec. 20-266o, I, Name certify under penalty of perjury the below named applicant worked as a tattoo technician for a
period of not less than years as follows
Name of applicant (please print)
Please enter full legal name
Signature of applicant:
Date:

MonthDayYear
Name of Supervisor (please print)
Please enter full legal name
License No.:
State:
Signature of Supervisor:
License No.:
State:
Subscribed and sworn to before me this day day of month
20 year
Signature of Notary Public:
Date:

MonthDayYear
My Commission expires:

MonthDayYear
Please return completed notarized form to:
Connecticut Department of Public Heath
Tattoo Technician Licensure
410 Capitol Ave., MS# 12APP
PO Box 340308
Hartford, CT 06134
Fax: 860-707-1931
Email: Dph.healingarts@ct.gov
Should be Empty:

Public Health: Tattoo Practice Affidavit