Dreamline Tattoo and Piercing State Consent Form

STATE OF MISSOURI DIVISION OF PROFESSIONAL REGISTRATION
First and foremost, we want to thank you for wanting to participate in our fundraiser. However, this does not guarantee you a slot for the fundraiser. This event is a first come, first served event. This is to speed up the paperwork and get you on the list quicker.
PATRON CONSENT
OFFICE OF TATTOOING, BODY PIERCING AND BRANDING

3605 MISSOURI BOULEVARD

PO BOX 1335

JEFFERSON CITY, MO 65102-1335

TELEPHONE: (573) 526-8288

FAX: (573) 526-3489
PATRON'S NAME (FIRST, MIDDLE, LAST):
PATRONS DATE OF BIRTH

MonthDayYear
Date
PATRON'S RESIDENCE/CELL PHONE NUMBER
PATRONS ADDRESS STREET CITY STATE ZIP CODE
PATRON'S DRIVER LICENSE NUMBER (must have driver's lisence the day of the event for confirmation purposes)

YOU MUST BE THE AGE OF EIGHTEEN, PLEASE SUBMIT DRIVER LICENSE NUMBER.
PATRONS DRIVER LICENSE NUMBER
TATTOOBODY PIERCING
If you are getting a peircing, where are you wanting it?
YESNO
YESNO
If yes, when?
YESNO
YESNO
YESNO
YESNO
YESNO
YESNO
YESNO
Should be Empty: