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2. Application for Tattooing and Body Piercing Establishment License
   Note: A floor plan and equipment layout, drawn to reasonable scale, must be submitted for the proposed establishment.
4. Establishment Name
6. Establishment Phone Number
7. Fax Number
9. Establishment Address
11. City
12. State
13. Zip
15. Type of Ownership

    1. Corporation
    2. Partnership

    1. Sole Proprietorship
    2. Other*
16. *If other please state type of ownership.
18. Name of Owner
    (if applicable)
19. Phone Number
21. Residence Address
23. City
24. State
25. Zip
27. Corporation Name
    (if applicable)
29. Chief Corporate Officer
30. Phone Number
32. Residence Address
34. City
35. State
36. Zip
38. List name, address, and telephone number for all additional corporate officers.
40. I certify that the above information is correct to the best of my knowledge.

    1. Applicant's Signature

    By checking the signature box you are signing this form.
41. Date
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46. Print Only

* indicates a required field