Tattoo Tech: Training Permit

Public Health: Tattoo Technician Student Training Permit

DPH Data Management and Governance (PLIS)
INSTRUCTIONS TO THE APPLICANT:
1. Have the supervising tattoo technician complete Part II of this form and both the applicant and the supervisor must sign the form in the presence of a notary public.
2. Upload the completed form when applying online or fax it to (860) 707-1931.
3. Upon receipt of this form by the Department, the applicant will be notified when an eligibility determination is made.
4. Should you change supervisors, a new permit will be required and you should arrange for the former supervisor to submit verification of the total number of months and hours completed.
PART I: TO BE COMPLETED BY THE APPLICANT
Name:

First NameLast Name
Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Date of Birth:

MonthDayYear
Signature of Applicant:
Date:

MonthDayYear
PART II: TO BE COMPLETED BY THE SUPERVISING TATTOO TECHNICIAN
Printed Name:
Shop Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email Address:
example@example.com
CT Tattoo Technician License No.:
I certify that I own or am employed in the facility where the student will receive supervision. I acknowledge that I am responsible for personally supervising this applicant’s practical training and experience in tattooing.
Signature of Supervising Tattoo Technician:
Date:

MonthDayYear
NOTARIZATION:

On this day day of month 20 year , the individuals listed above personally appeared before me, who being duly sworn says that they are the persons referred to in the foregoing application and that the statements made
herein are true in every respect.
Should be Empty:

Public Health: Tattoo Technician Student Training Permit

PART I: TO BE COMPLETED BY THE APPLICANT

PART II: TO BE COMPLETED BY THE SUPERVISING TATTOO TECHNICIAN